28th International Conference

The International Society for Quality in Health Care
28th International Conference
Hong Kong Convention and Exhibition Centre
Patient Safety:
Sustaining the Global
Momentum
using e-health, health technology,
education, research and policy
14th - 17th September 2011
Abstract Book
Contents – Poster Display
0010 How Clinical Governance helps in driving organization’s improvement in private hospital
0011 IMPROVING PATIENTS’ EXPERIENCE BY IMPLEMENTING PATIENT’S DISCHARGES AT WARD LEVEL IN KPJ
SEREMBAN SPECIALIST HOSPITAL, MALAYSIA
0018 Institutionalizing Quality in Health Care: A Process of Sustaining Change
0020 Effectiveness of antibiotics utilization control of National Health Insurance in Taiwan
0024 Appropriateness of the utilization of hospital resources in Saudi Arabia: Implications for health services quality
0026 The Awareness Transforming Process among Family Members Who Refused Tracheostomy for VentilatorDependent Patients
0027 Fall Prevention Video is effective to enhance patient education on fall prevention
0028 Effectiveness of Cardiopulmonary Resuscitation Refresher Workshop on Enhancing Nurses’ Knowledge in
Resuscitation – a follow up study
0029 A Project to Medical and Surgical ICU Nursing Staff Accuracy in Nursing Assessment
0030 THE RELATIONSHIP BETWEEN NURSE'S INTENT-TO-STAY AND ORGANIZATION CLIMATE
0031 Premature Baby Interim Ward Introduction and Promotion
0036 How effective is the Accreditation, licensee and other external assessment process as tools for Quality Movement in
Healthcare ?
0044 Castle Peak Hospital ( CPH ) 24 Hotline Services
0053 “Gut” versus Guidelines: How do Emergency Physicians Make Clinical Decisions?
0054 Analysis of Adverse Events in Patients Presenting to the Emergency Department with Acute Respiratory Distress
0055 The project of implantation of changing position skill to lower down the incidence rate of bedsore formation during
hospitalization
0056 Improving Patient Safety for Repeat Prescription by introducing a Pilot Repeat Prescription Program
0057 Investigation and Prevention of adverse drug events in a primary care setting in Hong Kong
0062 Work analysis of general ward nursing care and nursing assistant in a medical center of south Taiwan.
0063 The Prediction of Health Care Outcomes after Total Hip Replacement using the Charlson Comorbidity Index in
Korea
0065 Effect of the Innovative Portable Illuminating Oral Cleaning Suction Device on the Improvement in Patient Oral
Cleaning
0072 Improving quality of care by implementing a consultant-delivered service
0077 A Fuzzy-Rule-Based Approach to Fall Detection
0080 A multi-level of Patient Safety Culture Effect on Safety Performance－The Case of Nurse
0084 Surveillance of Abnormal Liver Function among Chronic Hemodialysis Patients: A Single Hospital Experience in
Southern Taiwan
0086 Analysis of Actions Following Adverse Patient Safety Events: Lessons Learned for Preventing Reoccurrence
0088 Seamless and Effective Stroke Rehabilitation Program in Tung Wah Eastern Hospital
0089 Prioritizing interventions against medication errors – the importance of a definition
0091 Access Block: The Application of Variability Management in Emergency Department
0094 Provision of X ray portable service on Public Holiday/ Statutory Holiday/ Sundays in a Hong Kong regional Hospital
0096 Prophylactic Antibiotics Uses in Thyroidectomy and Risk Factors for Surgical Site Infection
0098 Effective media advocacy strategies for quality and safety professionals.
0100 Blame and Accountability
0101 Study on the Effect of Two Educational Intervention Program on Performance of Nurses' Conveyance of
Gastroscopy-Related Knowledge to Patients
0102 Engaging Patients with Diabetes to Improve Diabetes Care Measures using LEAN Methodology and Individualized
Patient Reports
0103 A document management system that clinician staff actually use and like
0105 A “Virtual Toolbox” to Review Adverse Events in Critical Care Patients
0108 PHSA Near Miss Project: Paying Attention to Near Miss Patient Safety Events Prevents Actual Harm to Patients
0109 STAR - Sharing Techniques And Responsibilities – A Collaborated Approach to integrate Primary and Tertiary Care
in Dysphagia Management
0111 Are Spanish patients ready to overcome paternalism in clinical practice?
0112 Promoting Quality Culture – Cross-departmental Learning Quantitative Survey
0113 Psychiatric Service Enhancement: REHAB LAUNDRY A REHAB LAUNDRY program had been piloted from
3Q2010 to 1Q2011 in a male psychiatric ward.
0114 Structured emergency preparedness enhancement
0116 HIV RELATED KNOWLADGE, ATITUDE, PRACTICE AND STIGMAAMONG DENTISTS IN GEORGIA
0117 Cultivation and maintenance of safe ergonomic practice in patient transportation service through “Individualized
Behavioral Coaching (IBC)”
0118 Better Teamwork Climate Was Associated with Lower Catheter-Related Bloodstream Infection and Unscheduled
Return to Intensive Care Units-the Taiwan Patient Safety Culture Survey
0119 Relationships among Caregivers’ Burden and Quality of Life of Female Spouses of Chronic Obstructive Pulmonary
Disease Patients
0120 Enhancement of customer satisfaction through improvement of observance rate of scheduled time and
reinforcement of guidance on waiting time
0121 Surgical Colonoscopy – a Safe and Simple Journey
0122 Enhancement Program to Reduce Incidents in Phlebotomy Team – Wrong Specimen Container Used for Blood
Taking
0129 Prognostic models based on administrative data alone inadequately predicted the survival outcomes for critically ill
patients at 180 days post-hospital discharge
0132 Project to improve the accuracy of rehabilitation in burn patients
0133 Interprofessional practice, patient safety and Junior Medical Officers: will they ever be united?
0134 New idea for Old problem: CADENZA Community Project – Health-social Partnership Transitional Care Model
(HSP- TCM) for post-discharged Elderly
0137 Performances of Hospitals that have undergone 4 Cycles of the Malaysian Society for Quality in Health (MSQH)
Hospital Accreditation Program
0139 Measuring patient safety culture in the University Hospital of Monastir (Tunisia)
0140 Continuous Quality Improvement to Reduce Rates of Medication Errors in Hospitals: an absolute necessity
0142 The relationship between social capital and internal coordination
0144 Accreditation Survey Feedback from Hospitals for 2009 and 2010
0149 Effect of Y-shape Extension Tube Development
0151 Fighting for safety: a battle between health providers and consumers in China
0152 Enhancement of Patient identification During Drug Issuing Process to Patient in Out-patient Pharmacy and
Standardization of the Practice among NTWC Hospital Pharmacies.
0153 Outcome of MSQH Surveyors Training Program 1998-2008
0154 Reduction of initial response time in Acute Myocardial Infarction patients
0156 Strategies used to improve the understanding of PICU nurses to ECMO
0159 "Noiseless OR Project" for noise reduction in Operating Room
0162 Emergency Department Clinical Instability Criteria: starting patient safety systems at the hospital front door
0163 Performance of Malaysian Hospitals Undergoing Focus Surveys in 2007 to 2009
0166 Measuring Outcome of Hospitals Surveyed Using the 3rd Edition of the Malaysian Hospital Accreditation Standards
from Years 2009 to 2010
0167 Stimulating hospital accreditation: what can hospital federations do?
0171 Comprehensive evaluation of the perceived usefulness of a set of hospital accreditation standards
0173 A trial of short notice surveys in two accreditation programs: views of accreditation surveyors and health care
organisational staff.
0174 An empirical comparison of performance on short notice surveys with advanced notice surveys in two accreditation
programs
0175 Identity check and patients’ satisfaction on the quality of ultrasound service, United Christian Hospital
0180 Incidence and preventability of adverse events in surgical patients in Monastir (Tunisia)
0182 Impact of a tool for structuring actions plans for patient safety: a randomized controlled trial
0185 Suggested Guidelines for ASA Physical Status Rating is Facilitating Classification Consistency in Group Practice
Hospitals
0187 Measuring Duration of Preparation Towards MSQH Accreditation for Public and Private Hospitals in Malaysia
0188 Lessons Learned from the Surveillance of Clostridium difficile Infection at a Tertiary Care Hospital
0189 An Audit on Length of Stay & Outcomes of Major Trauma Patients Resuscitated in Regional Hospital before
Secondary Trauma Diversion
0190 dBasePNP - Innovative Primary Nurse Program designed to Save Nursing Time and improve documentation
0191 Quality and Safety enhancement on Total Joint Replacement (TJR) through Clinical Pathways in Kowloon Central
Cluster (KCC)
0193 The project of promoting the completeness of coronary syndrome patient education in the ICU
0194 Implementation of an innovative “Audible Drug Label” to enhance Medication Safety
0197 Introduction of C-Arm Fluoroscopy Successfully Enhancing Patient and Staff Safety in Double Contrast Barium
Enema
0199 Re-design the patient delivery process in a severe learning disability hospital in Hong Kong
0201 Measuring Patient Safety Culture in Tertiary Hospital, Saudi Arabia
0202 A Preliminary Study of Adverse Drug Events and Medication Errors in Saudi Arabia
0203 Adherence to Institute for Safe Medication PracticeLabel Guidelines in Riyadh Hospitals, Saudi Arabia
0204 The Impact of Medication Discharge Counselling by Pharmacist on Adverse Drug Events and Patients
Adherence
0206 Waiting time reduction for electrolysis surgery in trichiasis and distichiasis
0208 Epidemiology of Hospital Falls on Acute Care Wards in Japan
0214 A Collaborative Pediatric Cardiac Critical Care Team Model is Associated with Improved Outcomes in Children
Following Surgery for Congenital Cardiac Defects
0216 Preliminary results of a program for patients with severe mood disorders, schizophrenia or delusional disorders on
healthcare services utilization
0217 Managing the performance of senior doctors: building engagement through an integrated, clinically based
credentialling process.
0219 A prospective cohort study on factors influencing the development of pressure ulcers in Hong Kong Private Nursing
Homes
0221 Solifenacin or Tolterodine, which one is better for treatment of overactive bladder syndrome in Chinese Women?
0223 Redesigning the ICU Nursing Discharge Process; A Time Series Study using Statistical Process Control to
Demonstrate Process Improvement
0227 Feasibility, acceptability and utility of an e-cardiovascular risk platform amongst physicians and patients in the
primary care setting.
0228 Combating MRSA Infection through Safety & Quality Management on Environmental Cleansing Program
0229 Application of a surgical ward nursing care and information systems effectiveness of the quality of the process.
0230 Development of An Exceptional Apple Culture
0231 Extra healthcare costs associated with antimicrobial prophylaxis in colorectal surgery by using profiling data at a
university hospital in Japan
0232 Project of Improving the rejected Rate of Specimens in a Neurological Ward
0233 Improving hospital environment through LEAN and GREEN.
0234 Medical Clinic Accreditation Program In Malaysia: A Pilot Survey
0236 Improvement of Home Care on Traumatic Ambulatory Surgery
0239 Evaluating Nursing Practice on NHHD training: Promoting patient independence
0240 The use of multiple strategies in monitoring and improving the quality of artificial arthroplasty
0241 Hospitals’ benchmarking: it can be conducted.
0251 Six-sigma approach to improve process of outpatient clinic and patient’s satisfaction
0252 Risk Management and Clinical Characteristics of Patients Treat for In –hospital Accidents
0253 The Effect of Leadership Behavior and Safety Culture on Safety Performance－The Case of Nurse
0254 A Randomized Controlled Trial of an integrated care model of Telephone Nursing Support Service for Psychiatric
Patients Discharged from an Acute Psychiatric Unit in Pamela Youde Nethersole Eastern Hospital
0256 Applying Healthcare Failure Mode and Effect Analysis (HFMEA) to improve the Hemodialysis service quality in the
regional hospital
0257 The relationship between severity score and costs of patients with mechanical ventilator in medical intensive care
unit in Taiwan
0258 Reduce the rate of DM patients with poor glycated hemoglobin
0259 The Design and Evaluation of an Individualized Medication Instruction sheet-A Pilot Study
0262 Enhancement of Personal Information Security – e-media Disposal Campaign at Kowloon East Cluster Hospitals
0263 A Program to Decrease the Blood Infection Rate of Port-A from an Evidence-Based Practice
0265 Additional medical costs associated with Falls/Slips based on administrative profiling data at a rural university
hospital in Japan
0266 The project for improving the success rate of “Door to Balloon”
0268 Early Initiation of Maternal-Newborn Skin-to-Skin Contact in Delivery Suite and Breastfeeding Rate of Tuen Mun
Hospital
0270 Promote nursing quality in reducing the incidence rate of pressure ulcers
0276 Use of Caring Model to Reduce the Incidence of Incontinence Dermatitis of a Certain Internal Medicine Ward
0277 Early defibrillation in the wards by nurse-initiated defibrillation: application of health technology
0278 Title: Enhanced Patient Falls Management: Attaining the Next Level with Strategies and Innovations
0283 Pilot Study on Introducing Community Health Call Centre Support to Residential Care Homes for the Elderly
0285 Comparison of hand skin injury between rub and scrub sterilizing techniques in operation room staffs
0288 Safety and Quality Managing Program on Prevention of Infiltration and Extravasation in Intravenous Treatment in
O&T Department
0290 Hospital nurses’ knowledge translation: Evidence based practice, error occurrence, and job satisfaction
0293 Implementation of an Experience feed back committee (EFBC) and impact on prevention and risk management in
radiotherapy.
0294 USE OF HANDHELD DIGITAL DEVICE AT BEDSIDE TO IMPROVE QUALITY OF NURSING CARE
0301 Discussing the Effect of Improving the Level of Oral Care for Oral Cancer Patients who Received Surgical
Treatment
0302 Improving the Accuracy of Oral Care for Post Surgery Patients by Nurses
0304 Project to Enhance the First-time Success Rate of Urine Sample Collection From the Urine Bag in Hospitalized
Children
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1
1
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0305 Patient and Staff Safety during Pandemic –Safer and Smarter Ways Ho SM , Leung LM , Leung KM , Law SL
Ward 13A, Isolation Ward, Department of Medicine & Geriatrics, United Christian Hospital
0306 USING OF ROOT CAUSE ANALYSIS TO PREVENT SUSPECTED INCOMPLETE STERILIZED EVENT IN THE
PROCESS OF HYDROGEN PEROXIDE PLASMA STERILIZATION
0307 A four-year action research project examining interprofessional learning (IPL) and interprofessional practice (IPP)
across a health system
0309 Reducing central line associated bloodstream infections and ventilator associated pneumonias by standardizing
practices: sustained success
0312 The incidence and nature of in-hospital adverse events in Portugal: contribution to drive research and innovative
approaches to safety improvement.
0313 Integration of two international models of accreditation in a quality system management structured for improvement.
0316 Degree of implementation of the Patient Safety Action Areas at hospital level in Andalusia.
0320 A survey on medication knowledge and experience of patients in Taiwan
0322 The Relationship Between Patient Safety Culture and Incident Report Rates in Taiwan
0323 Analysis of inpatient suicides in health care institutions from Taiwan Patient Safety Reporting System
0324 The use of surgical checklist in operating rooms in Taiwan
0325 The experience of encouraging clinical workers to practice evidence-based medicine by a campaign in Taiwan
0327 REDUCING ERRORS DERIVED FROM INPATIENT CHEMOTHERAPY PRESCRIPTION ORDERS BY UTILIZING
HOSPITAL INFORMATION COMMUNICATION SYSTEM
0329 Promote breastfeeding by the certification program on Baby-friendly hospitals and clinics
0330 Hospital accreditation and its impact on patient satisfaction with hospital-based care
0332 To streamline the process of escorting Castle Peak Hospital in-patients with acute physical problems to general
hospital for assessment
0333 Promote caring culture for health workers in hospitals in Taiwan
0334 Factors Related to Health Outcome After Unplanned Extubation in a Nationwide Incident Reporting System
0335 An Project of Improving An Explanation before Gastrointestinal Endoscopy for Health Examiners
0336 Clean Hearts- Keeping Little Hearts Infection Free
0337 Exploration of Reasons for New Nursing Personnel for Leaving Employment
0338 Oral Health Education for Residential Aged Care Facilities Carers
0339 A case control study for quality care of patients with NSTI
0341 Assessment of CT dosage as a measure of service performance and patient safety: results in paediatric group and
lessons learnt.
0342 Streamlining UTIs
0344 The analysis of drug disposal on patient medication behavior in a medical center
0346 The implementation of CHARM, an oncology patient information management system at a specialist cancer hospital.
0347 Dynamic internet mediated teamwork case management of high frequent emergency department users
0348 Comparison of effects of disclosure training of adverse events between medical students and resident physicians
0349 Application of Radio Frequency Identification (RFID) for Surgery Scheduling Management
0351 HFMEA model : prevent an inappropriate initial dose prescribing
0354 IMPROVING DRUG SAFETY OF CLINICAL TRIAL SUBJECTS BY UTILIZING INFORMATION TECHNOLOGY
0357 PATIENT SAFERY CULTURE SURVEY IN COMMUNITY HOSPITAL
0366 Continuous Quality Improvement on the Discharge Process of Orthopaedic Patients
0372 Nurse-Led Prostatic Screening Clinic for Early Identification and Management of Patients with Lower Urinary Tract
Symptoms
0373 Independent Predictors of Peri-operative Outcomes in Orthopaedic Surgery: Influence of Timing of Preoperative
Myocardial Infarction and Stroke
0374 Business Intelligence and Cloud Computation Application for Healthcare Quality – The Use of National Healthcare
Insurance Reimbursement Data
0375 Decrease of waiting time and improvement of outpatient satisfaction
0378 Obstetric Incident reporting in Ministry of Health (MOH) Hospitals, Malaysia 2008-2009
0380 Development and validation of a clinical prediction rule to identify the patients with higher risks of ADEs during
hospitalization: the JADE Study
0383 A Delphi study for the development of quality indicator system of psychiatric hospitals in Korea
0384 Computerization of frozen section examination for patient safety and turn around time (TAT) reduction
0386 Measuring Users’ Satisfaction in a Tertiary Psychiatric Unit in Hong Kong
0391 Option of ‘No Sedation’ for Babies in Nuclear Medicine – Continuous Quality Improvement (CQI) Project
0394 Analysis of the accredited continuing education activities in Andalusia related to prevention of central venous
catheter related-bloodstream infections
0395 Re-alignment of Occupational Therapy Service to Improve Quality of Care for Orthopaedic Patients
0396 The importance of aligning registries monitoring quality and safety with nationally endorsed Operating Principles for
Clinical Quality Registries.
0398 Implementation Results of Post-buccal Cancer Surgery Care Education
0402 Implementation of a model for management of individual development plans in the Health Care System of Andalusia
0404 Outcome improvements after implementation of an outcome-driven quality management system – Analysis on the
hospital level
0405 INCREASING ACCESS TO BIRTH SPACING INFORMATION FOR MARRIED COUPLES IN NORTHERN
NIGERIA
0407 Evaluation of an Innovative e-Health Technology in ICU by the Users
0408 Service Quality Improvement Programme with e-Health Technology in ICU
0409 The ascent of work efficiency through improvement of operating system in rehabilitation therapy units(Physical
therapy, Occupational therapy, Speech therapy)
0414 Upgrade the Accuracy and Completion Rate of Nursing Instruction for Post-TUR-P Urinary Incontinence Patients
0417 Using electronic checklist to improve the efficiency of intravenous thrombolytic therapy in patients with acute
ischemic stroke
0423 Systematic and prospective risk assessment at a university hospital operative room
0424 Patient recall after misuse of a bloodletting instrument at an outpatient clinics
0428 Epworth Eastern Excellence – We Can Make a Difference
0429 Get behind it! Taking the pressure off in the Emergency Department.
0430 Association between nonverbal behavior and quality of disclosure of adverse events
0433 Integrated approach to patient relation management using e-Feedback System
0434 National Clinical Quality Registries
0436 Enhancing Quality and Safety Care for Patients with Invasive Mechanical Ventilation (IMV) in Hospital
0437 Satellite Pharmacy Room – An effective way to manage medication inventory in wards
0438 The Roles of Operating Room Nurses on the Electronic Nursing Records – An Example of the Radio Frequency
Identification System
0441 The Quality of Care in Adult Patients with Community-Acquired Pneumonia in a Regional Teaching Hospital
0442 Moving Patients? Impact of Nursing Unit Transfers and Room Changes on Patient Safety Outcomes
0443 Fostering Information Security Culture in Kowloon East Cluster Hospitals
0445 Building staff-patient partnership through engaging staff to listen to patients’ voice
0451 The improvement of work effectiveness through the enhanced discharge review process
0452 Towards the research and development of an automatic cancer notifications system
0458 Discussion on the needs of the families of dying patients.
0459 ‘The Boarding Pass’ to Safer Imaging
0461 FIVE MOMENTS THAT MAKE A DIFFERENCE: OUTCOMES FROM THE AUSTRALIAN HAND HYGIENE
INITIATIVE
0462 Safe Surgery Saves Lives – the implementation in Hong Kong NTE Cluster
0463 Addressing Quality and Safety Issues in Data Reporting: A Statewide Endoscopy Information System for NSW,
Australia
0465 Using the multimedia to improve the effects of nursing education in patients with open pulmonary tuberculosis
0469 Standardized infusion solutions for the risk reduction of pharmaceutical incompatibility
0471 Improving clinical management and surveillance of Healthcare Associated Infections through structured
microbiology requests and reports in the eHealth environment
0472 Nurse-Led CPAP Clinic for patients with Obstructive Sleep Apnoea Syndrome (OSAS)
0475 The study of the satisfaction degree for family members in liver transplant intensive care unit on using video visiting
0480 Taking an in-depth look at how to meet the newly hired nurses’ needs in dealing with workplace adjustment and
competence enhancement
0482 Framework for a future national healthcare performance measurement system in Norway
0483 Enhance the home care capacity of primary caregiver to patients undergoing flap for reconstruction after head and
neck cancer surgery.
0485 Inter-professional clinical handover in the emergency department: tools for patient safety
0487 A clinical audit on the process performance of smoking cessation in a primary care clinic in Hong Kong
0490 Time from breast cancer diagnosis to initiation of therapy as a quality indicator
0494 Multidisciplinary low-cost program on rapid improvement in prostate biopsy service
0496 Study on Improvement of Maintaining Blood Phenytoin Levels within Therapeutic Range for Patients with Epilepsy
0497 Educational disparities in quality of diabetes care in a universal health insurance system
0499 Good practices in nursing to ensure the patient safety
0502 Project to Reduce Pain Scale Scores During Intravenous Cannulation in Children
0503 Quality assessment of diabetes care: looking at measures of adequate and timely actions
0504 Engaging Continuing Education and Quality Improvement Professionals in LEAN Healthcare Quality Improvement
0511 Using Private Cloud Concepts to Improves ICU Admission Services
0513 Efforts to Reduce Door-to-Balloon Time in Acute ST-Elevation Myocardial Infarction: Results from 15 Primary
Percutaneous Coronary Intervention Centers in Taiwan
0516 Improving the Follow-up rate After the Abnormal Pap Smears Screening
0517 The project to improve nursing care chemothrapeutic guideline in pediatric cancer ward
0519 Evaluation of an Australian National Clinical Handover Initiative Pilot Program: lessons and outcomes
0532 Trends in mortality for AMI, stroke and hip fracture patients admitted to Norwegian hospitals during 1997-2001 and
2005-2009. Preliminary results.
0533 How should patient transferrals be accounted for when calculating in- and-out-of-hospital mortality as a quality
indicator?
0536 Determinants of quality of life in rheumatoid arthritis
0540 Characteristics and Consequences of Falls, and Risk Factors for Injuries Due to Inpatient Falls for Selected
Hospitals in Taiwan
0545 A study of Taiwan regional teaching hospital in-patients and the factors for the incidence of pressure ulcer
0546 Patients' and health care workers' evaluations of a patient safety advisory
0551 The quality assessment of total parenteral nutrition in the hospital
0553 Identifying the practice challenges to improve services for children presenting with suspected physical abuse and
neglect.
0558 Service performance of General Ward Ventilator Team in Queen Elizabeth Hospital, Hong Kong
0559 Clinical outcomes evaluation using risk adjustment methodology: the example of Interventional cardiology.
0563 The effectiveness of streamlining elective surgery care in the public sector: the Alfred experience
0565 The Investigation into Diminishing the Incidence of Incontinence Associated Dermatitis in Medical Intensive Care
Unit
0566 Did the mortality rate reduced in patients with unexpected deterioration? Analysis from adverse-event reports.
0567 Prioritizing quality indicators for colorectal cancer care
0570 The Development and Validation of a Scale to Measure Clinical Preceptor’s Teaching Performance
0571 A comprehensive rehabilitation program in partnership with community resources to improve the outcome of
patients with Congestive Heart Failure
0572 Evaluation of the Association of Total Parenteral Nutrition Related Infection
0574 Consumer participation – from passive to partnership
0577 The improvement project of artificial reproductive medicine injection procedure
0580 From Anxiety to Confidence – Engaging and Enhancing Confidence of Nurses in Preparing Queen Mary Hospital,
Hong Kong for Accreditation
0584 Improvement of Health Care Standard through the ‘Incidence Occurrence Report’
0588 Applying HFMEA to Increase the Patient Safety of Chemotherapy: A Teaching Hospital's Experience in Taiwan
0589 Reducing unplanned-extubation rate in neurosurgery intensive care unit
0591 An integrated and intensive day-rehabilitation model for patients after total knee replacement (TKR) in Pamela
Youde Nethersole Eastern Hospital (PYNEH)
0595 Review of ‘Fall Management’ through Patient safety rounds in acute/ rehabilitation hospitals.
0596 IMPROVEMENT IN PRESERVATION AND DRUG EXPIRATION AFTER ACCREDITATION
0599 Opportunity algorithm analysis of the importance of medical service and satisfaction in the emergency department
0601 Audits of Clinical Records in the Professional Competence Accreditation Process: the submitted proofs verification.
0606 MONITORING OF THE IMPROVEMENTS IMPLEMENTED IN RELATION TO THE PRESERVATION AND DRUG
EXPIRATION
0611 The Development of a Quality Improvement Hub for NHS Scotland
0612 Success factors in the adaptation of a health care quality accreditation model in an international context
0616 Enhancement Program on Pressure Ulcer Prevention Management for Supporting Staff
0617 Program of All inclusive Care for the Elderly: An Evidence-Based Patient Centered Comprehensive, Collaborative
and Coordinated Care Model
0618 Is Higher Quality Associated With Lower Racial Disparities in Cardiovascular Care?
0619 Did public reporting improve patient outcomes in the United States from 2002-2008?
0621 High 5s Project – Adaptation and Implementation of International Standardized Operating Protocols for Patient
Safety in Germany
0623 Evidence based approach in nursing patient with total joint replacement: Introduced an evidence based clinical
protocol on prevention of deep vein thrombosis (DVT)
0624 Hospital Acquired Infections: Development and Validation of a Predictive Model Using Automated Clinical Data
0625 Evidence based approach in prevention of Extended spectrum beta-lactamases (ESBL) cross infection.
0628 Hospital Pay-for-Performance in the United States – Do National Comparisons Work?
0630 Comparison of hospital discharges at a Brazilian healthcare plan hospital network using Geoprocessment and
Diagnosis-Related Groups (DRG)
0632 Measuring Knowledge
0634 Characteristics of High Performing Healthcare Services: A Review of Comparative Outcome Studies
0636 A Project of Enhancing Nursing Staff’s Recognition of Chemotherapy and Proficiency of Applying Port-A
0639 Increasing the Effectiveness of a Patient-oriented Pain Free Hospital Program
0640 Improvement of patient’s care through promotion of activity by hospice ward nurses
0641 Evaluation and effect of pay for performance demonstration project for acute myocardial infection in Korea
0642 Improving Voluntary Hospital Incident Reporting
0643 A multidisciplinary falls evaluation programme for elderly fallers presenting to an emergency department ( ED )
reduced re-attendance and functional decline.
0645 Second Global Patient Safety Challenge -- Pre procedure & Time Out check
0647 The promotion of oral hygiene for patients at a hospice ward in Taiwan
0648 Cross-sectoral cooperation to improve the processes of Pap smear screening for cervical cancer
0649 The Influence of Service Innovation and Organizational Performance on Knowledge Management in a Nursing
Section
0652 RCA to Decrease the Incidence Rate of Leaving an Acupuncture Needle on the Patient’s Body in Chinese Medicine
Clinic
0653 Value, Validity, Consistency: The Senior Medical Officer Performance Review.
0654 Process engineering (PE) ameliorates performance of a chemotherapy outpatient clinic (CC): A tool for constant
improvement in functioning strategies
0655 Using Healthcare Failure Mode and Effect Analysis techniques to improve inpatient medication safety
0656 Evaluating the implementation of an extended infusion Piperacillin-Tazobactam dosing strategy at a large tertiary
care teaching hospital
0659 High Tech, High Touch: New Cardiac Patient experience from Assessment to Rehabilitation
0660 Team skills training in health care: when, what & how
0662 Pharmacist-conducted Medication Reconciliation with Patient Counseling at Hospital Admission to Improve Quality
of Pharmaceutical Care
0664 Incidence of pressure ulcer at operating theatre in an acute regional hospital in Hong Kong.
0665 Legislated Health Care Standards: Changes after Three Years of a Regulatory Process - Self Assessed Compliance,
Monitoring Capability, Quality Improvement Activities
0667 Patient safety compromised by failure to follow-up of test results: a review of the evidence for ambulatory patients.
0668 Risk Indicator for Hospitals: Legislated Health Care Standards and Complaints to an Independent Regulator
0672 Australian baby boomers’ perceptions of quality of health care
0673 Measuring Patient Outcomes to Improve Care – Is the Circle Complete?
0676 PAPER-LESS Project: Medical Record Forms Management System
0679 A Pilot Study on the effect of a modified Sedation Management Protocol on Weaning of Mechanical Ventilation
0684 A Paediatric Unit Dosing Intravenous Admixture Service with Information Technology Support to Strengthen
Medication Safety
0686 Developing Radiology Dashboard indicators in order to decrease errors and bring core process improvement in a
teaching hospital in Pakistan
0687 Control of Linen Loss Upon Discharge Through NEATS to Old Aged Homes
0688 The Causes of Medical Error in Malpractice Cases in Taiwan from 2000 to 2009
0689 Strategies to Increase Hospital Bed Turnover – An Example of Improvement of Inpatient Bed Transfer
0690 Excellence Beyond Standard Medical Care:- Achieving High Service Efficiency in Medical Report Processing
Through Lean Management Principles
0691 National Quality Assessment of Diabetes In Korea
0692 Improve the Satisfaction of the Patients with Use of Femoral Artery Pressure Belt
0693 To reduce excessive follow-up appointment days for all immobile patient who are discharged from a medical ward in
a major tertiary hospital in Singapore
0695 Impact of hospital accreditation on quality of care – the role of culture and management style on quality of care
0698 The development of clinical Indicators for acute care hospitals in Japan
0699 Effect of the evaluation on antibiotics prescription for acute upper respiratory infections in ambulatory care in Korea
0700 An Evaluation of the implementation of RFID Wireless Body Temperature Monitoring System to enhance Patient
Experience and Work Efficiency.
0702 2D Barcode System for accurate patient identification in Anatomical Pathology Laboratory
0703 Strategies to Decrease the Rate of artificial kidney/dialyzer clotting in Hemodialysis patients
0704 Lean and medication safety in streamlining drug administration rounds in Paediatric Unit
0705 Discussion of the Innovation of Integrated Care and Interface with Primary Care
0706 A Dramaturgical Approach towards Education in the Attitude and Skills in Conflict Resolution in Hospital Care
0707 Use of concurrent feedback mechanisms in reducing the blood culture contamination by house officers
0708 Stakeholders in an organization focused on healthcare accreditation
0713 The impact of using dynamic inventory management system, to increase operational efficiency, improves end user
satisfaction; reduce inventory carrying and distribution costs.
0714 Impact of Active Lifestyle Therapeutic Exercise Program on function recovery and vascular risk factors control in
secondary stroke prevention
0716 To improve the image quality of Whole-Spine and Lower Extremities on Long Film for obese patients.
0719 Relational capital as an instrument for the improvement of the flow of knowledge
0720 Strategies for assessing clinical microsystem performance
0723 Patient experience of an empowerment programme of severe COPD patients using an interactive telephone
network delivered by trained volunteers
0727 Pharmacist-led Medication Reconciliation in Singapore General Hospital
0728 Associations between dress codes of white coats and inners and the favourable view of the hospital users.
0730 Development of a Quality Framework for Health service provision in the Kingdom of Bahrain.
0733 High 5’s international Standard Operating Protocol Medication Reconciliation: how to reduce medication errors in
hospitals with 75%.
0737 Implementation of a team training program improved unplanned extubation in a medical intensive care unit
0741 2010 regulation requires in France accreditation of point-of-care testing according to ISO 22870 - The experience
of a Paris laboratory
0745 The Effect of Pay- For- Performance Demonstration Project for Caesarean Section rate in Korea
0746 The Effects of the National Quality Improvement Program on the Prophylactic Antibiotics for Surgery in Korea
0748 The Effects of the Quality Assessment on the Prophylactic Antibiotics on the volume of antibiotics
0749 Cost-effective laboratory result printing in a Hong Kong Acute Care Hospital
0751 Capacity Building on Hospital Infection Control with QUALITY Strategies
0753 Patient-centred ambulatory surgery care – a holistic approach to quality, efficiency & safety
0761 How sensitive are Hospital Standardised Mortality Ratios to variations in coding and formulation?
0762 Mandatory accreditation of medical laboratories under ISO 15189 in France – The Saint-Antoine hospital experience
0764 Improving clinical practice guidelines in the Netherlands: awareness and use of guidance and tools for guideline
development, dissemination, implementation and evaluation.
0766 Treatment outcome of clinical pharmacist-managed anticoagulation service – systemetic review.
0767 The long-term effects of pay-for-performance on quality of care
0768 Hand hygiene accredited continuing education activities in Andalusia
0769 The effectiveness of reducing aspiration pneumonia in neurological patients using the breakthrough series (BTS)
model
0770 Differences between the best and worst hospitals in the U.S.: Implications for disparities in care
0772 Impact of the Andalusian Patient Safety Observatory’s reporting and learning system on the reduction of risk in
primary healthcare centres
0773 Approach to accreditation from a processes perspective
0774 The effect of Quality Improvement Program for hospitals with lower performance of Acute Stroke treatment in Korea
0777 The effectiveness of applying Six Sigma approach in reducing error rates of pediatric outpatient prescriptions
0782 Using team-based learning to improve medical team training program
0783 Develop a integrated information system of documentation in maternal-neonatal nursing and indicators management
for the Baby-friendly Hospital Initiative
0784 The compliance in implementing fall prevention standard among medical-surgical nursing staff in a regional teaching
hospital in Taiwan
0792 Evaluating quality of care in Hong Kong through identification of Potentially Preventable Readmissions within the
current unplanned readmissions indicator framework
0795 Node and mentor centres network in the Andalusian Patient Safety Observatory
0797 Strategies for improving patient safety culture in hospitals: a systematic review
0799 The High 5s Project – The experience of implementing a patient safety standard operating protocol
0801 The integration of administrative health data with data from a vascular registry improves indicator-based monitoring
and auditing
0804 Delivering Greater Value with a Collaborative Patient Throughput Program: “The Amazing Race”
0808 Communication at the bedside to enhance patient safety: a ward-based team approach.
0812 Sustaining Hand Hygiene - Difficult but not Impossible
0814 A cost-effective empowerment programme for orthopaedic patients with chronic pain syndrome
0817 Implementation of management system for tuberculosis patient
0819 A fall prevention program developed to empower patients, family and staff, and to increase awareness of the
consequences of a fall
0820 What input do consumers have in the accreditation of long term aged care and how can we improve this?
0829 Impact of Universal Prenatal Screening Program for Down Syndrome in a Local Obstetric Unit in Hong Kong
0830 Using Information Technology to Improve Medical Communication and Satisfaction of Acupuncture Therapy.
0833 Patient Satisfaction Surveys – A Drive for Sustaining Quality Improvement in Hospital Services
0835 Documentation Errors in the Emergency Department: if it’s not documented, it’s not done
0836 Review of Oral Chemotherapeutic Agents Used on Medical Wards - An Interim Analysis
0837 Thai International Healthcare Standard Training Center – Think outside the box
0839 The Prevalence of Medication Errors in the Emergency Department: the reported incidents are just the tip of the
iceberg
0840 The Development of a Clinician Credentialing System in a University Affiliated Hospital
0841 Evaluation of the quality of documentation in shoulder dystocia after regular drills
0842 The 6-PACK program to decrease falls and fall injuries in acute hospitals: Protocol for a cluster randomised
controlled trial
0843 New workflow of Holter ECG monitoring
0844 The effect of information system on improving post-medication record at one medical center in Southern Taiwan
0845 Clinical Review: The role for consumers representatives
0846 Up went the Periscope …we stuck our neck out to take a look at risks with risk exposure everywhere….
0847 Psychometric Validation of a Fall Risk Assessment Tool in the Oncology Setting
0849 Improved data compilation using WHO Conceptual Framework for the International Classification for Patient Safety
as backbone of organisation risk register
0851 Analyzing the attributes of long-term residential care for persons with profound intellectual and multiple disabilities in
Hong Kong
0853 Explore of Factors related to Bloodstream Infection for Central Vein Catheter in Cardiac Intensive Care Unit
0863 Using of the Healthcare Failure Mode and Effects Analysis to underwent magnetic resonance imaging evaluation of
the patient safety
0864 The APBEST Award – An International Recognition of Quality Hospital Management with reference to the European
Quality Award (EQA) Framework
0866 Responding to medical emergencies: system characteristics under examination (RESCUE). A prospective multi-site
point prevalence study in Australia.
0867 Enhance the use of cross-team model of rehabilitation nursing for stroke patients to guide the implementation rate
0869 Using information technology to improve the quality of cancer imaging diagnosis
0872 Risk for trauma patients the effectiveness of fall prevention intervention study
0874 Care of a gangrenous pyoderma patients with altered body image nursing experience
0879 MATCH UP Medicines – reducing patient harm through medication reconciliation
0880 A National Standard for the Application of Tall Man Lettering
0881 Enhance Linen Supply Service in a public hospital through Collaboration and Teamwork
0883 A Delirium Intervention and Prevention Quality Improvement Project
0886 Accreditation for Sustainability - A Safer Organisation
0887 Improving reporting of monitoring visits in long term care.
0890 Use Turnaround Times and Patient Satisfaction to measure the effect of Improvement on Service Quality in Hospital
OPD Pharmacy
0891 Evaluation on the association of aggressive vancomycin dosing and nephrotoxicity: a retrospective analysis
0894 Patient Safety Walkround at Hospital level – A way to enhance patient safety
0898 To improve patient-care process by reducing report turnaround time through the use of technology (voice
recognition system).
0901 Change Management Framework of a Total Revamp of Patient Catering Service in a 47 Years Old Acute Hospital to
Improve Patient Experience
0902 Embracing safety and service improvement in a major hospital relocation exercise
0904 Promoting A Mediating Culture in Healthcare Complaint Management
0905 Medical Error and Autopsy in Japan: a Nationwide Study Regarding Views of the Public and Physicians.
0906 How to create a Tipping Point? Super fast track implementation of a new supply model of medical consumables to
hospital wards
0912 “My chart in my hand”; development and short term analysis of a mobile personal health record
0915 The Wide Range of Applications of RFID to Improve Patient Safety– Experience of Taipei hospital, Department of
Health
0916 Accountability and Clinical Pathways in Japanese Hospitals
0917 Applying a surgical safety checklist across both the pre and post operative surgical periods.
0919 Enhancement of the Nursing Assessment of Dysphagia Capacity for Patients with Stroke.
0924 Enhance capability in activities of daily living (ADL) in Geriatric patients.
0929 The effectiveness of intervention in decreasing serum phosphorus value for incident hemodialysis patients
0930 Ensure Safe Surgery by Adopting Surgical Safety Checklist
0932 One Stop Comprehensive Admission and Response (OSCAR) Programme - An ambulatory alternative to
hospitalization
0933 Implementation of a Simple Tracking Identification System for sterilization process
0934 Hospital at night – Enhancement in Nursing Senior Coverage
0940 Safe Practice Evaluation - Prevent inadvertent administration of Penicillin to patients with known drug allergy
0941 Identify Correct Post-operative Patient discharge to Correct Ward by Facilitating of Discharge Call Slip
0942 Introducing lean management to improve the patient experience in Specialist Outpatient Clinic
0944 Oral hygiene improvement project for patients with oropharyngeal intubation in the intensive care unit (ICU)
0950 Executive Leadership Development in Health Services: the Hong Kong Experience
0951 Psychiatric nursing care to promote care models - the case of psychiatric patients to improve oral hygiene
0954 Revolutionary Changes in Human Resources Training & Development System to Enhance the Work Efficiency and
Boost Customers’ Satisfaction
0956 Awareness of Previously Diagnosed Diabetes and Hypertension and Its Association with Changes in Blood Glucose
Levels and Blood Pressure
0960 The journey from paper to electronic records in a specialist practice in Australia
0963 A national web system for monitoring the implementation of the Recommendation issued by the Italian Ministry of
Health for preventing sentinel events
0968 Focus Group interviews and concept mapping as tools to explore the patients’ perspective in measuring the quality
of radiation care
0971 Body Donation: from a wish to a guideline
0972 Application of Quality Control with the Modified Humanoid Comic Chart (mHCC) of Acupuncture and Disposition
Record to Improve the Care of TCM Ward
0984 Integration of Statistical Management by Construction of Medical Device Management
0986 Being open and supporting patients and staff when serious patient safety incidents occur: the current state of
practice in the English NHS.
0994 Beyond the Root Cause Analysis: the cessation of scabies outbreaks by the application of an Enriched SystemOriented Events Analysis model
0999 Management of waiting lists in Serbia
1003 Measuring effectiveness of an inpatient anticoagulation safety program in a large tertiary care institution
1011 Accrediting Clinical Practicum Centre for Specialty Training Courses in Public Healthcare Setting in Hong Kong
1013 Timely conversion of IV-to-PO antibiotics: an effective strategy to reduce length of stay of patients with Community
Acquired Pneumonia
1015 Staff Competence Enhancement on
1020 Quality upgrade and enhancement in decontamination
1021 The effectiveness of reducing neurological patient falls using the breakthrough series (BTS) model
1023 Use of and attitude towards complementary and alternative medicine by patients with lung cancer
1024 Accrediting social sector services in Denmark – early experiences from a sector without established evidence base
1025 An integrated program to enhance quality of patient care in local urological operations in a high volume medical
center
1027 Keep up with Health Informatics - IT-Smart Ambassador Scheme
1032 Implementation of an e-technology to reduce waiting time of blood drawing in ambulatory patients
1037 The Efficacy of performing Health literacy program on Diabetes patients
1040 Healthy Staff: An Essence to provide quality care to patients - CQI Programs in Enhancing Healthy Staff
1041 To review the long-term results of Malone Antegrade Continence Enema (MACE) procedure in Chinese paediatric
patients with neuropathic bowel associated with spinal cord disease.
1046 Patient Risk Factors for Adverse Events During Congestive Heart Failure Hospitalizations
1048 Designing and Implementing a Patient-Centered Hospital Building in Ensuring Medical Privacy and Patient Safety
1049 Operating room management: old story and new solutions.
1052 Application of Agency for Healthcare Research and Quality (AHRQ) patient safety indicators in Japan
1053 Variation of in-hospital mortality for acute myocardial infarction by hospital volume quintiles –
1057 Validity of quality indicators: A systematic literature review on the readmission rate
1059 Comparing Root Cause Analysis (RCA) findings of significant adverse events in high reliability organizations:
aviation industry and a local hospital
1061 Planetree model of quality as a tool for improvement process and patient satisfaction in a general and private
hospital
1063 Surgeon and hospital-related factors associated with revision arthroplasty of the hip
1067 A Holistic View of Assistance Procedures
1069 Impact of hospital accreditation: a new look at the literature
1072 Accreditation Canada Leading Practices: Improving the process to drive healthcare quality and safety
1074 Systematical Quality Assurance And Patient Safety In North Rhine-Westphalian Hospitals – A Long Term
Observation Of Medical Treatments And Patient Recovery
1076 Prevention of re-admission in post kidney transplant patients in KCMH
1077 Using lean to improve emergency blood transportation to cardiovascular operating room in KCMH
1079 Reduction of intravenous high alert medications administration errors in CVT ward
1091 Psychometric Properties of the Safety Attitudes Questionnaire (SAQ) - Portuguese version
1092 An enhancement program of Perioperative Nursing Documentation in Hong Kong
1095 The Adoption of High Involvement Human Resource Management Practices in Employer-of-Choice Organizations.
Evidence from Canadian Nursing Homes
1097 From Pencil & Eraser to the Electronic Age – Eastern Palliative Care (Victoria, Australia) moving forward with Client
Information Management
1098 Assessing Progress on Quality Improvement in Ontario Hospitals using a MBNQA Framework
1100 An Enhanced Workflow in SOPD Registration Process
1109 Streamlining the laboratory specimen collection process to enhance patient safety in a cluster of primary care clinics
in Hong Kong
1110 Direction of occupational therapy in substance abuse service of Hong Kong
1113 Safety, Recovery and Seclusion Reduction in acute mental health
0010
How Clinical Governance helps in driving organization’s improvement in private hospital
Abd Aziz Abd Rahman, Maygala Arumugam, Nishazini Mohd Basir, Noorzura Zahri
KPJ Seremban Specialist Hospital, Seremban/Negeri Sembilan, Malaysia
Introduction:
KPJ Seremban Specialist Hospital started its operation in year 2005 with 56 beds and increased it to 109 beds in the
following year. As at December 2009, the beds stand at 130 beds. It is a private one stop medical and therapeutic centre
offering a comprehensive range of medical, surgical and 24 hours emergency services. In July 2009, the hospital has
been awarded with 3 years Hospital Accreditation certification by Malaysia Society Quality & Health (MSQH). In our
hospital, clinical governance is the main vehicle for continuous improvement to maintain high standard of patient care.
Objectives:
To achieve the following objectives:
i.
Improve the quality of patient care and safety through implementation of clinical indicators
ii.
To improve customer satisfaction.
iii.
To safe guards hospital by reducing potential litigation or medico-legal cases.
iv.
To comply with statutory duty to seek quality improvement activities through clinical governance.
Methodology:
A retrospective study was conducted from January to December 2008 before the accreditation of the hospital compared
to January to December 2009 after the accreditation activities. Even though the hospital was accredited in July 2009, the
compliance to the standard started from January 2009.The data collected are as follows:
a.
For Patient Safety Indicators - O&G, Anaesthesia, Surgical and Medical.
b.
Benchmarking exercises - Patient satisfaction, Clinical and Non Clinical Incidents
c.
Intervention of Safety & Quality Improvement Activities - Toping up system for medication and medical supplies,
Diabetic card, coding sticker and IV mobile drip holder.
Results:
For 2009, medication errors had reduced by 30%, needle prick injuries reduced by 62.5%, thromboplebitis reduced by
19%, sentinel events reduced by 100%, compliance of hand hygiene among clinical staff had improved by 94% and
patient falls had reduced by 24% as compared to 2008.
Number of verbal complaints had reduced by 34% in 2009, inpatients negative feedbacks decreased by 41%, positive
inpatient’s feedbacks increased by 32% as compared to 2008. Number of potential litigation cases had reduced to 75% in
year 2009 compared to year 2008.
For year 2009 the revenue was 12% higher and PBT increased by 5% as compared to year 2008.
Discussion
With the implementation of the Clinical Governance, the hospital was able to achieve its objective of improving the quality
of care.
Assessment for patient fall was measured thru KPJ FRAT and prevention of patient fall was done through the use of a
special identification such as falling star, orange band,caution sticker and fall prevention policy.
For paediatric patients ,new bed padding was introduced to prevent fall. With those initiatives, patient fall among adults
was reduced by 48% and for paediatric patients there was no fall at all in year 2009.
The main contributor for the significant reduction of needle prick injury was the introduction of management on needle
prick injury by the infection control committee.
By improving safety and quality of patient care, the customer satisfaction index had also improved and the hospital was
able to generate a better financial performances in year 2009 compared to year 2008.
There are many factors contributing to the positive growth of the hospital financial performances. However, from the study
it was found that the Clinical governance is one of the important factor that contribute to the positive growth of the
hospital’s business.
Conclusion
Full compliance to the Clinical Governance had facilitated the hospital to achieve a good clinical outcome, improved
customer satisfaction and reduce potential litigation. The hospital had also enjoyed a positive growth in term of revenue
and profit.
References:
1. Dr J.Aliza, Introduction to Clinical Indicators, KPJ Healthcare Berhad 2010.
2. Patients Safety Goals by KPJ Healthcare Berhad, 2009 & 2008
3. Incidents report by KPJ Seremban Specialist Hospital 2009 & 2008
4. Clinical Indicators KPJ Group of Hospitals by KPJ Healthcare Berhad, 2008 & 2009.
5. Clinical Indicators study by KPJ Healthcare Berhad: 2008 & 2009
6. Charles S. How can hospital performance be measured and monitored?, HEN (Health Evidence Network)
evidence for decision makers (WHO Europe). August 2003.
0011
IMPROVING PATIENTS’ EXPERIENCE BY IMPLEMENTING PATIENT’S DISCHARGES AT WARD LEVEL IN KPJ
SEREMBAN SPECIALIST HOSPITAL, MALAYSIA
Abd Aziz Abd Rahman, Nishazini Mohd Basir, Noorzura Zahri, Maygala Arumugam
KPJ Seremban Specialist Hospital, Seremban/Negeri Sembilan, Malaysia
OBJECTIVE:
KPJ Seremban Specialist Hospital with 130 beds is one of the private hospital in Malaysia which belong to KPJ
Healthcare Berhad, the biggest change of private hospitals in Malaysia.
Before end of 2009, patient’s discharge is done through central discharge counters located at the ground floor .All patients
or relatives have to go down to settle their bills upon discharge. Based on the patient’s feedback received many
complaints on the hassle of going up and down during discharge and on long waiting time to settle the bills. To improve
patient’s experience, the hospital had implemented the new system of discharge by doing discharges at ward’s level.
st
The new system was implemented in 1 January 2010. Patients or relatives can settle their bills at the counter of every
ward. For in mobile patients, the ward staff will go to their rooms to process the bill.
The objective of this study is to compare the outcome of the new process compared to the old process through patient’s
feedback .A retrospective study were conducted from July 2009 to June 2010.
METHODOLOGY
All patients admitted will be given a feedback form. Collection of the forms will be done on daily basis. Feedback forms
that had been collected will be and tabulated accordingly based on the rating. The number of complaints related to the
hassle of discharge process and waiting time were collected and tabulated to get a comparison between the old systems.
Data were collected for sixth months before the implementation of the new system and sixth months after the
implementation.
RESULTS
From July to December 2009, 5,060 of feedback, from January 2010 to June 2010, 5,657 of feedback were collected.
There were 95 numbers of complaints on the hassle of the discharge process before the implementation of the new
discharge system and no more complaint on the hassle of discharge process after the implementation of the new system.
For the waiting time, 16 cases of complaints before the implementation of the new system compared to 8 cases when the
new system were implemented. Therefore, there were no more complaints on the hassle of discharge and 50%
improvement of waiting time after the implementation of the new system.
DISCUSSION
From the data collected it was clearly seen that when the new discharge system was implemented from January 2010
there was no complaint at all on the hassle of discharge process except for a small number of complaints on the
discharge time. The complaints on the discharge time were related to the time of getting the approval from the insurance
companies to approve the payment. In some cases especially for complicated cases involving more than one doctors, the
insurance companies would require more time to go into details with their medical advisors before committing on the
payment. This process is beyond the control of the hospital as the healthcare providers. However the data had clearly
shown a drastic reduction in the number of complaints on the waiting time after the implementation of the new discharge
system.
CONCLUSION
The new discharge system implemented in January 2010 had improved patients perception on the discharge process and
this will further enhance the good image of the hospital .This is inline with the objective of improving perception in term of
non clinical reputations as stated by McKinsey & Company. Good perception in the long run will further improve the
business performance of the hospital
Reference:
1. Caring Bridge, Improve Patient Satisfaction.
2. Customer Satisfaction Index by KPJ Seremban Specialist Hospital: 2008
& 2009; Public Relations.
3. Patients litigation statistics by PCCRC (Patient, Complaint and Conflict Resolution committee) report: 2008 &
2009.
4. http://www/bartsandthelondon
5. www.kingford.org.uk
0018
Institutionalizing Quality in Health Care: A Process of Sustaining Change
2
1
Saira Siddique , Nadeem Ahmad
1
2
Department of Health, Khyber Pukhtunkhwa, Pakistan, German Technical Cooperation, Islamabad, Pakistan
Objective
This paper would describe the approach adopted by of Department of Health (DoH) of Khyber Pukhtunkhwa (KP)
province to establish and maintain Quality as an integral and sustainable part of the health system.
Context/ Problem/ Interventions
The Health Sector Reform Unit (HSRU) of Department of Health (DoH) of Khyber Pukhtunkhwa (KP) province in Pakistan
with the support of German Technical Cooperation (GTZ) has been actively involved in developing and implementing
quality management approaches in healthcare since 2006. The initial approach was an externally driven, standard based
approach for improving quality of healthcare services with partial success. It was soon realized that changes to the
system in ways that permits it to better results are essential. Thus a conceptual and organizational framework was
developed and adopted to analyze, plan, build and sustain efforts to produce quality healthcare. It consists of eight
essential elements and is being implemented in a phased process for institutionalization of QM. The elements include the
internal environment composed of policies, leadership, organizational values and adequate resources; organizing for
quality with a clear delineation of roles, responsibilities, and accountability; support functions to sustain implementation of
QM including capacity building, information and communication, and rewarding arrangements.
Results/ Effects of Change
The framework and the phased process is assisting the KP health system progress from having little QM efforts, to initiate
awareness and experimentation with QM activities, to expansion with the aim of ultimately leading to consolidation of
these efforts and finally reaching the vision of fully developed and institutionalized QM activities. Till now out of 24 districts
of KP, primary and secondary facilities in 10 districts where the QM initiative started rank 3.8 on an increasing scale of 1
to 4 (baseline survey showed 1.4 ranking). The utilization rate of the facilities improved has almost doubled in the last one
year. Patient satisfaction has improved from fair (rank 2) to excellent (rank 4). Provider’s knowledge, attitude,
performance and behavior have improved. 40% of the private sector hospitals have been registered with Health
Regulatory Authority and are voluntarily improving their quality of service delivery in order to bid as a service provider with
BISP (Benazir Income Support Program) for below poverty line population.
Lessons Learnt/ Messages
QM institutionalization is an ongoing process where QM activities become integrated into the structure and functioning of
the healthcare system. It is not a linear process and the essential elements may mature in a sequence or in a less
coordinated fashion. The quality management in health care in KP is on the move in a constructive direction. However, it
is expected that the fully integrated and institutionalized quality management will take many years. The experience with
implementing quality management in a developing and resource constrained setting like KP province of Pakistan will lead
to a better understanding of how the framework and methodology for institutionalization can be applied and to further
development of the methodology.
0020
Effectiveness of antibiotics utilization control of National Health Insurance in Taiwan
Wen-Fuh Tseng, Chao-Ming Huang, Min-Chu Lin, Ju-Hsun Chang
Bureau of National Health Insurance, Taipei, Taiwan
Objective:
Antibiotics abuse could cause drug-resistance in patients. This study is to evaluate the effectiveness of antibiotics
utilization control measures of National Health Insurance in Taiwan.
Methods:
In order to avoid antibiotics abuse, the Bureau of National Health Insurance (BNHI) in Taiwan has implemented the
following control measures:
1. Set regulations to restrict the use of antibiotics on patients who get the upper respiratory infection (URI) such as
common cold or mere viral infection. Antibiotics can only be prescribed to patients with clinical proof of bacteria
infection.
2. In principle, limit the usage of antibiotics for clean surgery not exceeding 24 hours after operation.
3. Develop four quality indicators associated with antibiotics usage and feedback these information through the Virtual
Private Network (VPN) system quarterly to all hospitals and clinics, which have contracted with BNHI. These four
indicators are
(1) The utilization rate of antibiotics in ambulatory care,
(2) The utilization rate of antibiotics in URI patients,
(3) The utilization rate of antibiotics in clean surgeries which include total knee replacement, total hip replacement,
thyroid resection, repair of femoral and inguinal hernia, and
(4) The infection rate of total knee replacement surgery within 90 days of after operation.
4. Find the outlier-hospitals/clinics which show extreme figures in these four quality indicators and apply reinforced
management on these hospitals/clinics such as professional review and fraud auditing etc.
5. Disclose quality information publicly on the website of BNHI.
Results:
After implementing the above-mentioned control measures, the utilization rate of antibiotics in ambulatory care has
dropped from 20.24% in 2001 to 9.79% in 2009. Similarly, the utilization rate of antibiotics in URI patients has also
decreased from 16.54% in 2001 to 4.42% in 2009. However, for clean surgery, the 1-day utilization rate of antibiotics
after surgery rose from 24.01% in 2003 to 41.15% in 2009; the two-day-and-above utilization rate has decreased from
48.85% in 2003 to 31.18% in 2009. And the proportion of clean surgeries that did not use antibiotics at all remained at
27.14% in 2003 and 27.68% in 2009. Relatively, the infection rate of total knee replacement surgery within 90 days of
after operation has dropped from 0.36% in 2004 to 0.25% in 2009. These results have shown the prominent effectiveness
of the antibiotics control measures.
Conclusions:
The Bureau of National Health Insurance in Taiwan has carried out the antibiotics utilization control measures since year
2001 to reduce unnecessary use of antibiotics. The measures include setting drug reimbursement regulations, regular
feedback of quality information to hospitals and clinics, reinforced management and quality information disclosure to the
public. Three antibiotics- utilization-rate indicators in ambulatory care, URI patients and clean surgeries and one
infection-rate indicators in total knee replacement surgery were adopted to monitor the effectiveness of such measures.
The findings of this study demonstrated that utilization control measures have remarkable effectiveness in avoiding
antibiotics abuse.
0024
Appropriateness of the utilization of hospital resources in Saudi Arabia: Implications for health services quality
Saad Alghanim
King Saud University, Riyadh, Saudi Arabia
Objectives: To assess the appropriateness of hospital resources utilization in Saudi Arabia, to determine whether
utilization differs according to the type of ownership of hospitals (MOH, other governmental agencies and private sector)
and to determine factors influence utilization of hospital resources.
Methods: The study employed a self-administered questionnaire to collect data from hospitals’ staff (physicians, nurses
and administrators) and was designed to collect data on variables relate to patients, physicians and hospitals which were
thought to influence resources utilization. Descriptive statistics and analysis of variance (ANOVA) were used to determine
the variables which may explain the differences among hospitals in the appropriateness of the resources utilization.
Results: The results showed that hospitals differ in their resources utilization according to their ownership. Regardless of
the hospital ownership, a substantial percentage of respondents perceived that hospital resources were inappropriately
utilized. However, respondents in private hospitals perceived that their hospital resources were more appropriately utilized
compared to other health care sectors. The study identified a number of factors relate to patients, physicians and
hospitals’ organization which have influenced the hospital resources utilization.
Conclusion: The study highlighted the importance of factors which influence the hospitals’ resources utilization in Saudi
Arabia. Understanding these factors by health decision makers is important to optimize the appropriateness of the
hospitals’ resources utilization. Further research, on a larger scale of hospitals is needed to examine the extent and the
appropriateness of the utilization of health resources in the various regions of the Kingdom.
0026
The Awareness Transforming Process among Family Members Who Refused Tracheostomy for VentilatorDependent Patients
HUNG HSIAO-HUI
Chi Mei Medical Center, LIOU YING, TAINAN, Taiwan
Purpose
This study was to explore decision making process and psychological adaptation of family members who refused using
tracheostomy in ventilator-dependent patients. The essence of caring experience was uncovered through family
members’ inner subjective experience and resources they searched for.
Patients and methods
A phenomenological research design was adopted, and purposive sampling was used to recruit eight family members.
Data were collected using a semi-structured retrospective interview and were analyzed applying a reflective analysis with
seven steps including observing, accounting, reflecting, valuing, believing, and willing, experiencing, analyzing, and
examining.
Results
Results showed that awareness and decision making process of inner subjective experience of course of disease among
family members who refused tracheostomy for ventilator-dependent patients were: to bear physical and emotional labor,
including facing family who suffers from illness and provoking decisional conflict; to assess risk of treatment, including
searching for clarification, assessing loss and risk, and worrying about impairment of dignity and bodily integrity; to affect
the factors associated with decision making process of course of disease and then to regulate follow-up care, including
delegating decision making authority and assessing the execution and compliance of decision making.
Conclusion
The study suggests the need for understanding that the awareness of course of disease, And also suggests nursing staff
provide adequate medical information and enough time to respond to doubts, apply the effects of decision making culture
such as social norms, customs and culture, and give assistance as well as support in nursing and regulating follow-up
care. The study could help clinical nursing staff and the public understand the transforming process of awareness and
decision making of course of disease and could be a good reference for reflection on meeting the needs of patients and
family members at each stage.
0027
Fall Prevention Video is effective to enhance patient education on fall prevention
Eliza Ping Siu Shum, Tak Ki Chung, Viva Ho Ming Tam, Hak Kwong Man
Shatin Hosptal, Hong Kong
Introduction: Patient fall exists as a persistent problem in hospital settings and multi-factorial interventions have been
implemented such as individualized fall risk assessments, frequent monitoring of high-risk patients, alternative devices
(e.g. low beds, alarm devices), elimination programs and ongoing patient education. Fall incidents with similar scenarios
still occurred repeatedly. In order to enhance patient and carer education and to reinforce their cooperations on fall
prevention, video on Fall Prevention has been produced.
Patient engagement is important to prevent falls during hospitalization; fall prevention programs will never success without
patients’ participation. A fall prevention educational program in the format of video was designed to increase their safety
awareness on fall prevention and to enhance their cooperation.
Objectives: The Fall Prevention Video with 5 common hospital fall scenarios was produced for patients at risk and their
carers; aiming at increasing their safety awareness and become more cooperative towards healthcare professionals’
advice on fall prevention strategies
Methodology:
1. Analyses of all fall incidents in various departments of Shatin Hospital for the past three years were made. Five
common recurrent fall incidents were selected as the scenarios of fall prevention video shooting:
(i) Falls when families assisted patients to walk against the advice of healthcare professionals.
(ii) Patient falls due to elimination when they chose not to ask for staff’s assistance.
(iii) Patient falls related to use of walking aids of other patients
(iv) Patient falls related to inappropriate choice of footwear.
(v) Patient falls related to risky walking and improper sitting posture.
2. The video was produced in January 2009, besides distributing in Shatin Hospital, the video was also distributed to
different hospitals (BBH, PWH, AHNH, NDH, WTSH, PMH…) per request for broadcasting to target groups.
3. A satisfaction survey on the video was conducted from August to December 2009 to evaluate its effectiveness.
Results:
344 patients/ relatives / carers responded. Among the respondents, 59% were patients, 15% were relatives and 26%
were carers. 89.2% of the respondents agreed that the video could enhance their safety awareness on fall prevention.
83% of them believed that communicate and cooperate with healthcare professionals were of vital importance to prevent
fall. Moreover, 83% of the respondents thought that they could apply the skills learned from the video to their daily life.
Conclusion:
Effective fall prevention programs require active patient involvement, with the aid of video, patients and careers are
empowered for the knowledge, practical skills which may result in fall risk reduction.
0028
Effectiveness of Cardiopulmonary Resuscitation Refresher Workshop on Enhancing Nurses’ Knowledge in
Resuscitation – a follow up study
Eliza Ping Siu Shum, Chi Kin Ip
Shatin Hospital, Hong Kong, China
Objective:
Nurses working in New Territories East Cluster are required to attend CPR refresher Workshop in every 36 months, a
study about its effectiveness has been performed in Shatin Hospital in 2008 and modifications have been suggested; and
this is a follow up study aimed on the evaluation of the effectiveness of the workshops held by Central Nursing Division of
Shatin Hospital, identification of common misconceptions among nurses, study the relationships between demographic
data against the effectiveness of training sessions as well as recommending effective strategies to clarify the
misconceptions in the future CPR refresher workshops.
Method:
A pre and post test design was employed and using whole population sampling, and then conducted from January 2009
to December 2009. All workshop participants were invited to answer two identical questionnaires before and after the
workshop. The questionnaire contained 15 true-or-false questions focusing on CPR concepts on both BLS and ACLS.
Then comparisons are made to evaluate the usefulness of the training workshop. The Chairperson of the Central
Committee on Resuscitation in Shatin Hospital was invited to act as expert judge for validating the instrument, and all
questions were found relevant without any amendment. A pilot study was conducted on 1 December 2007. The aim of
the pilot study was to access the feasibility of the method of data collection. The target sample was 10 nurses comprising
WM, NO, APN, RN & EN. They were asked to complete the questionnaire, and all of them had completed the
questionnaires and did not report any difficulties in interpreting the questions.
Results:
One hundred and one nurses ranked from WM, NO, APN, RN and EN participated in the SH CPR Refresher Workshops
from January to December 2009 were invited to complete the questionnaires. A hundred usable (N=100) pair of
questionnaires were returned for data analysis. Response rate was 99%. The mean result for correct answers of preworkshop and post-workshop questionnaires was 7.79 (51.93%) with standard deviation (SD) 2.206 and 9.77 (65.13%)
with SD 2.112 respectively. It was observed that there was a 25.42% of improvement in knowledge after the workshop
and it was statistically significant on the improvement (**p<0.01). The Post-workshop result showed improvement from
1.15% to 110.71% on the 14 out of 15 CPR concepts, 7 out of 15 showed significant improvement (**p<0.01) and 1 out of
15 showed great improvement (*p<0.05) .
Throughout the analysis of the influence of demographic data towards the effectiveness of CPR training sessions, it was
no doubt that the higher ranking of participants demonstrated a higher correctness in post-test result. Nursing officers and
Advanced Practice Nurses even demonstrated a better knowledge of resuscitation before and after CPR refresher
courses than average (pre-workshop result of NO/APN versus mean: 8.5 versus 7.79 while post-workshop result of
NO/APN versus mean: 10.67 versus 9.77). Participants who have less than 10 years experience demonstrated a clearer
concepts on resuscitation before the training program but for those who have less than 2 years experience had a lower
correctness after the session.
Conclusions:
The SH CPR Refresher Workshop for Nurses was effective in enhancing nurses’ mastery of the BLS and ACLS concepts
on CPR. For enhancing knowledge and skills in CPR Refresher workshop for nurses, common misconceptions in CPR
guidelines were identified and effective strategies were recommended.
0029
A Project to Medical and Surgical ICU Nursing Staff Accuracy in Nursing Assessment
Shu-Chien Liu, I-Hui Wang, Min-Hua Tang, Hui-Lan Yu
Chang Gung Memorial Hospital -Kaohsiung Medical Center, Kaohsiung, Taiwan
Some nursing staff cannot evaluate the general condition of ICU patients and the meaning of laboratory data associated
with their cases. This could influence the nursing quality and the patients’ safety. Therefore, intensive care nurses’
enhancing the accuracy of nursing assessment is an important issue, and also hoping that, through further study and
improvement, this project will provide the highest quality of holistic patient care. In this Project from October 16 to October
29 2009, we used the checklist to evaluate the accuracy of nursing assessment in medical and surgical ICUs. It revealed
that the accuracy rate (63.4%) was much lower than we expected. The main reasons are: continuing education courses
focused on treatment of various diseases’ care, the intensive care nurses’ lack of knowledge, the lack of implementing the
nursing assessment, nursing assessment of inheritance according to experience, the lack of guidelines for nursing
assessment and the situational consistency of simulation training.
Purpose:
The goal of this project is to improve the recognition of nursing assessment and the accuracy of nursing assessment skills
of nursing staff.
Resolution:
1. Set up the guidelines of a nursing assessment; 2.Make CD-Roms about nursing assessment; 3.Use lecture and
simulation exercises strategies to teach nursing assessments and related topics.
Results:
The accuracy of the nursing assessment was improved (85.8%); the average score of recognition about nursing
assessment improved from 68.7% to 83.1%. Indeed enhancing the ability of intensive care nurses’ nursing assessment,
and the intervention of this project should continue in clinical delivery.
Conclusion:
For Nursing quality and performance improvement, we must proceed from the nursing staff competency requirements.
This project could improve the accuracy of nursing assessments, The project also made by nursing staff to review the
importance of clinical nursing assessment, the condition when the patient is not expected to change, if timely nursing care
through assessment found problems, this will reduce the status of the patient in crisis; it can also show Self-improvement
in the medical field of professional recognition. This project may be considered and referenced by relevant medical
organizations.
0030
THE RELATIONSHIP BETWEEN NURSE'S INTENT-TO-STAY AND ORGANIZATION CLIMATE
YA-TING KE
CHI-MEI MEDICAL CENTER, Tainan County, Taiwan
This research explored the relationship between nurse’s intent-to-stay and organization climate. The purposes of this
study were to： (1) Analyzing nurse’s intent-to-stay from four hospitals (2) Analyzing organization climates of four
hospitals (3) Exploring the relationship between the nurse’s intent-to-stay and organization climate (4) Exploring the
relationship between the nurse’s attributes and intent-to-stay (5) Inferring the reasons of nurses’ intent-to-stay. A crosssectional, descriptive and correlation research was design by using structural questionnaire method. It took random
cluster sampling and chose five units from every hospital according to the classification of departments, and then chose
nurses conforming to research’s conditions depending on certain ratio from four hospitals. It totally collected 207 cases.
The research’s result found that ：(1) the standardizing score of nurse’s intent-to-stay was 72.13, and there weren’t
significant differences from the four hospitals；(2) the standardizing score of organization climate was 66.45, and there
had significant differences ﹝F(3,203) =67.17,p=.00﹞； (3) three items getting the highest scores in organization climate
scale in sequence were as follows：”productivity will be raised if nurses are happy.”、“I think I am a capable member in
the team.”、“head nurse’s function in this department is to make work guidance and principles and let nurses be
responsible for their work.”；(4) the score of organization climate of local community teaching hospitals was higher than
academic medical centers in the same legal foundation；(5) the score of organization climate was higher, they were
significantly correlated（r = 0.19,p =.00） with intent-to-stay；(6) the important predicting factors for nurse’s intent-to-stay
were age, organization climate, the person’s work wills, working in intensive care unit, in other words, it meant that if
nurse’ s age was older, the score of organization climate was higher, and they were volunteers to work in hospitals, the
intent-to-stay became firm, but if they work in intensive care unit, intent-to-stay would lower.
This research’s result offered nurse managers some suggestions like choosing the volunteers to work in hospitals as the
prior choice, emphasizing human resource management, making good use of alternate training plans and letting
members to know organization climates of different units and bringing up effective and individual measures for intent-tostay, constructing a good organization climate for work and rising nurse’s intent-to-stay, and creating an excellent medical
service quality and efficiency.
Key words：Intent-to-stay, Organization climate, Human resource management
0031
Premature Baby Interim Ward Introduction and Promotion
FU MEI HSU, Te-Jen CHEN, Chiu-Mien Huang, SHUNEN-YIN WEN
CHI MEI MEDICAL CENTER, Tainan, Taiwan
Objective:
Returning the baby to community setting care from the hospital as secure, smooth, and on-schedule as possible for
premature babies is the goal of our discharge plan. Deliberate preparation prior to the discharge of preterm birth babies
can reduce the uncertainty and anxiety of family members, and improve the appropriateness of discharge.
Methods:
Often times, after the physician recommends that a preterm baby can return home for normal parental care, family
members begin to feel more worrisome than joy. They fear that when they take their child home, the baby may face many
problems such as inadequate oxygenation, apnea, bradycardia, feeding difficulties, and oxygen dependence. These
worries cause caregivers overwhelming psychological pressure, making them reluctant to take the child home as
recommended. Therefore, in order to boost the confidence of the parents to take care of the baby before actually
returning home, we established the Premature Baby Interim Ward, under the sponsorship of Premature Baby Foundation
and the great support of Chi Mei Medical Center since 2009, to allow the family members to learn premature baby
caretaking skills with the help and assurance of hospital healthcare personnel.
Premature Baby Interim Ward is currently established in the 5th floor pediatric ward of Chi Mei Medical Center.
Premature babies are admitted to the ward when they fulfill the criteria of body weight near 2,000 grams, stabilized
physiological parameters, and after an attending physician has determined that they may be discharged in the near future.
Results:
During the interim ward stay, the premature baby will continue to be cared by our medical team, including physicians,
nurses, social workers, nutritionists, and rehabilitation personnel to help parents understand the current status of their
baby, prognosis, treatment plan, and preparation for the required home care. Further, our healthcare team will teach and
guide the parents on the necessary caretaking skills, supplemented with education pamphlets, books and videos. As a
continuation of nursing knowledge and caring skills, parents will be taught how to measure vital signs, observe color
changes, read oxygen saturation monitor, apply basic first aid techniques, provide kangaroo care, pad back to clear
phlegm, feeding, bathing, changing diapers, caring for umbilical cord stump and doing rehabilitation exercises.
Furthermore, after the baby returns home, nurses will continue to follow-up baby’s home care developments.
Conclusions:
Chi Mei Medical Center Premature Baby Interim Ward has served families with premature babies since its establishment.
According to our premature childcare services satisfaction survey, ratings of satisfied and above reached 100%. More
importantly, premature children are discharged on-schedule, without a single unplanned readmission case. On the
homecare nurse visits of Chi Mei Medical Center preterm childcare program, family members give many positive
feedbacks, saying "the establishment of Premature Baby Interim Ward is very helpful for families of premature children
because of the simulation and education of homecare situation prior to discharge, thus enabling the caretaker to be less
afraid, and also more confident in taking care of the baby! "
0036
How effective is the Accreditation, licensee and other external assessment process as tools for Quality
Movement in Healthcare ?
HJ ABD AZIZ ABD RAHMAN, MAYGALA ARUMUGAM, NISHAZINI MOHD BASIR
KPJ SEREMBAN SPECIALIST HOSPITAL, SEREMBAN/NEGERI SEMBILAN, Malaysia
Introduction:
KPJ Seremban Specialist Hospital is a private hospital with a current bed strength of 130 beds. In year 2006, it has been
certified with ISO 9001:2000 certification and recertified during the transition audit of ISO 9001:2008 in year 2009. In July
2009, it has been awarded with 3 years Hospital Accreditation .
Objectives:
1. statutory requirements.
2. Increase patient safety & health care quality.
3. improve business operations.
4. enhancing staff education.
Methodology:
A retrospective study was conducted from January to December 2008 before the accreditation of the hospital compared
to January to December 2009 after the accreditation activities. Even though the hospital was accredited in July 2009, the
compliance to the standard started from January 2009.The data collected were as follows:
a.
For Patient Safety Indicators:
i.
Percentage of patients with length of hospital stay > 5 days after elective caesarean section.
ii.
Unplanned admission to the intensive care unit within 24 hours of surgery.
iii.
Rate of White Appendix
iv.
Percentage of Myocardial Infarction patients receiving Thrombolytic therapy within 1 hour of their
presentation at the Emergency department.
b.
Benchmarking indicators
i.
waiting time& number of complaints
ii.
Clinical and Non Clinical Incidents
c.
Result of external audit / surveyed findings
d.
Staff development and recruitment.
e.
Quality Improvement Activities
i.
Medication Diabetic card and sticker for preventing medication errors
Results:
No
Yr 2008
Yr 2009
(average)
(average)
0.47%
8
23%
75%
0%
5
12%
95%
min
min
min
30
60
30
0.3%
0.2%
N
Cli Capital
i l I Development
id
Human
0 4%
0 2%
Diploma, Post Basic Training, Bachelor degree and Master Degree
21
34
Indicators
Patient Safety
LOS > 5 days after elective caesarean section
Unplanned admission to ICU within 24 hours of surgery
Rate of White Appendix
% of Myocardial Infarction patients receiving Thrombolytic therapy
Standard
< 1%
0
5-20%
< 70%
within 1 hour at the Emergency department
Benchmarking
i.
Waiting time admission
Clinical incidents
3.7 -16%
DISCUSSION
O& G indicators had indicated a major improvement where there was no incidence of patients with length of hospital stay
> 5 days after elective caesarean section in 2009 compared to 0.47% in year 2008.Tthe unplanned admission to ICU
within 24 hours of surgery was reduced from 8 cases in 2008 to only 5 cases in 2009. Rate of white appendix had
improved from 23% in 2008 to only 12% in year 2009. The percentage of myocardial infarction patients receiving
thrombolytic therapy had improved to 95% in 2009 compared to 75% in year 2008.
For year 2009 the waiting time for admission was only 30 minutes compared to 60 minutes in 2008.For discharges the
waiting time had improved from 40 minutes in 2008 to 30 minutes in year 2009.The complaints had also improved from 75
cases in 2008 to 62 cases in 2009.
For clinical incidences the percentages had reduced from 0.23% in 2009 compared to 0.3% in 2008.The same trend can
be seen in non clinical incidences where 0.4 % was recorded in 2008 compared to only 0.2 in 2009.
Conclusion
Based on the data collected we can see clearly how various clinical and non clinical indicators, accreditation, licensee
and external assessment process had improved quality services
For ISO 9001: 2008 there was no conformance recorded in year 2009 and the hospital was awarded 3 years
accreditation .
Number of staff sponsored for further study increased from 21 in year 2008 to 34 in year 2009.
The figure on poor understanding of label was improved from 40% in 2008 to 32 % in 2009. Ineffective communication
had also being improved from 30% in 2008 to 29% in year 2009.
0044
Castle Peak Hospital ( CPH ) 24 Hotline Services
MUK KWONG CHAN, YIK LUN LEUNG, KAM WAH CHUNG, Kat WONG
Castle Peak Hospital, Hong Kong
Introduction
Discharged clients/ carers expressed that they were directed to different call numbers when they needed support or
advice from staff. Much time was wasted in the process. Clients were frustrated.
Each department and discipline has different telephone line for enquiries. The existing hotlines services were run by
Hospital Authority Head Office (HAHO) and Community Psychiatric Services, Castle Peak Hospital (CPS CPH) in different
models. However, there were no round the clock mental health hotline specially allocated for CPH discharged clients and
carers. It may be worthwhile to set up such services to support our clients in the local community.
Objective
To set up a round the clock mental health hotline for CPH discharged clients and carers.
Methods

A task force was set up in 2Q 2009. All stakeholders were involved, including doctors, ward nurses, MSW, CPS,
OPD staff.

A assessment form was designed for collecting data in 3Q 2009

In house staff training for telephone assessment started in 4Q 2009

FAQ list compiled in 4Q/2009

Hotline services piloted in 4Q/2009 and provided services to 10 wards in CPH.

Monthly review for services improvement & support
Results
146 calls were received from 9.11.2009 to 31.10.2010. Among the identified callers, 26% were relatives, 74% were
patients.
Enquired Issues
24.7% were related to physical problems ;29.4% were related to mental problems
32.9% were related to social problems ;15.8% were related to medication problems
22.6% were related to follow up problems ;2.7% were related to others problems
Services provided
0.68% needed report to police, 84.3% needed general advice, 26.7% advised to contact AED as required, 19.2% referred
to CPS, 15.7% referred to MSW, 39% referred to TMMHC, 23.3% referred to wards.
Time used
34 % call needed 5-10 minutes ; 37 % call needed 10-20 minutes
14 % call needed 20-30 minutes ;15 % call needed > 30 minutes
Conclusions
The CPH 24 hotline services tended to provide one- stop services for NTWC discharged clients and carers. Positive
feedbacks were collected from services users. The impact of telecare round the clock needed more in depth study.
The hospital management needed to:

Explore the possibility of revamping the existing hotline services of CPS NTWC with this hotline

Collect services users feedback

Extend the services scope to all departments in CPH

More structure and systematic staff training and develop a nursing supervisor role in handling mental health call

Allocate extra manpower as the call number increase
0053
“Gut” versus Guidelines: How do Emergency Physicians Make Clinical Decisions?
1
1
1
2
Lisa A. Calder , Alan J. Forster , Ian G. Stiell , Patrick Croskerry
1
2
Ottawa Hospital Research Institute, Ottawa, ON, Canada, Dalhousie University, Ottawa, ON, Canada
Objective:
To determine whether emergency physicians perceived their clinical decisions in general to be more experiential or
rational and how this compared to other physicians.
Methods:
We sent via postal mail a validated psychometric tool, the Rational Experiential Inventory (REI-40), to all emergency
physicians listed on the College of Physicians and Surgeons of Ontario website in November 2009. Forty statements were
ranked on a Likert scale from 1 (Definitely False) to 5 (Definitely True). We sent out an initial survey, reminder cards and
second survey to non-respondents. Analysis included descriptive statistics, Student t-tests, ANOVA and comparison of
mean scores with those of New Zealand cardiologists.
Results:
Our response rate was 46.9% (434/925). The respondents’ median age bracket was 41-50, they were mostly male
(72.6%) and most had more than 10 years clinical experience (66.8%). The mean REI-40 rational scores were higher than
the experiential scores (3.93/5 (SD 0.35) versus 3.33/5 (SD 0.49), p<0.0001), similar to New Zealand cardiologists (mean
rational 3.93/5, mean experiential 3.05/5). Female respondents’ mean experiential scores were significantly higher than
those for male (3.40/5, SD 0.49 versus 3.30/5, SD 0.48, p=0.003).
Conclusions:
Overall, emergency physicians favoured a rational decision making style rather than experiential; however, female
emergency physicians had higher experiential scores than males. This has important implications for future knowledge
translation and decision support efforts among emergency physicians.
References:
(1) Epstein S, Pacini R, Denes-Raj V, Heier H. Individual differences in intuitive-experiential and analytical-rational
thinking styles. J Pers Soc Psychol 1996; 71(2):390-405
(2) Sladek RM, Bond MJ, Huynh LT, Chew DP, Phillips PA. Thinking styles and doctors' knowledge and behaviours
relating to acute coronary syndromes guidelines. Implement Sci 2008; 3:23
0054
Analysis of Adverse Events in Patients Presenting to the Emergency Department with Acute Respiratory Distress
Austin Gagne, Ian Stiell, Alan Forster, Lisa Calder
Ottawa Hospital Research Institute, Ottawa, ON, Canada
Objective:
The objective of this study was to determine the preventability, type and severity of adverse events (AEs) amongst
emergency department (ED) patients discharged with the diagnoses of Congestive Heart Failure (CHF), Chronic
Obstructive Pulmonary Disease (COPD), and Community Acquired Pneumonia (CAP).
Methods:
We conducted a structured AE analysis of a prospective cohort of patients 50 years or older discharged from the ED with
CHF, COPD or CAP at two tertiary care EDs. A trained medical student abstracted pre-defined variables from charts and
constructed case summaries. We searched for all patients discharged from the ED who had flagged outcomes (death,
admission or return to ED within 14 days post index visit). AE determinations were made by a trained emergency
physician reviewer, using a structured, piloted process. Data were analysed with descriptive statistics.
Results:
Of 1200 enrolled patients, there were 68(5.7%) flagged outcomes and 20 adverse events (1.7%, 95% CI:1.1-2.3). There
were 47.1% (N=32/68) female patients and a mean age of 73.8(SD 9.5). Adverse events occurred among 9 patients with
COPD, 8 with CHF and 3 with CAP. The majority of AEs were preventable (N=18/20, 90.0%). The two most significant
types of preventable AEs were unsafe disposition decisions (N=9/18) and diagnostic error (N=8/18). One unsafe
disposition was a CHF patient sent home despite an ambulatory oxygen saturation less than 90%. In terms of severity
among the AEs, there were 2 deaths, 13 admissions and 5 patients who returned to the ED.
Conclusions:
Patients with CHF, COPD and CAP experience a high percentage of preventable AEs, of which an unsafe disposition
decision or diagnostic error was the primary cause. This suggests a need for improved emergent diagnosis and
disposition decision making for these patients.
0055
The project of implantation of changing position skill to lower down the incidence rate of bedsore formation
during hospitalization
Ya chun Hsiao, Chou Mi- Chon, Tsay Hsiu–YU, Huang Shan
Chang Gung Memorial Hospital, Chiayi, Taiwan
Objective:
The project was aimed at investigation of the recognization of caring staff to prophylaxis of bedsore formation and caring
skills, to lower down the incidence rate of bedsore during hospitalization, to reduce the painful sensation of patients and
fatal complications, to promote the professional skills and accompanishment of caring staff, and finally to nursing quality.
Material and Method:
Under TQIP score monitoring system indicated yearly-incidence of 1.12% (totally 239 events) in this hospital, which was
higher than that of other regional teaching hospitals. Thus, the checklist for bedsore caring was designed to investigate
the administeration of bedsore caring by the caring staff. The investigation was undertaken during Feburary, 2010 to
observe the caring staff in daily practice. The results yielded a correction rate of 68% for caring bedsore. Among the
items, incorrect changing position was 43%, incorrect use of prothesis was 32% and unawareness of cathether during
chaning position was 24%.
Results:
The project committee and caring quality staff designed open questions to evaluate the factors to influence bedsore
caring in 42 caring staff. By analysis of the results by caring, medical policy and facility, the results was contributed to the
devoid of caring knowledge of caring bedsore in nursing staff, lack of caring standard and flow-chart of bedsore caring
and changing position, lack of prothesis, training, and real practice of changing position. Thus, measurements were
undertaken by case analysis and in-office training, establishment of caring standard and flow-chart, excution of clnical
practice teaching, clnical monitoring regularly, and setting prothetic pillow for changing position. The incidence rate was
lower down to 0.03% and the correction rate was 92%, which were statistically significant.
Conclusion:
The prophylaxis and caring of bedsore was cornerstone in acute and chronic medical caring. The project provided inoffice education to nursing staff with recognization of bedsore caring, and corrected the errorous practicing skills, such as
to changing position correctly, and providing optimal prothetic pillow for use. In the other hand, caring quality would be
promoted by investigation and monitoring the flow-chart for caring staff to practice and accompanish. Therefore, the
project would provide a reference to units with similar quality.
0056
Improving Patient Safety for Repeat Prescription by introducing a Pilot Repeat Prescription Program
Ka Wae, Tammy Tam, Kon Hung Kwok, Kwok Keung Ng, Chiu Yee, Luke Tsang
Professional Development & Quality Assurance, Department of Health, Hong Kong
Objective.
To evaluate the clinical outcomes of chronic patients after implementation of the Pilot Repeat Prescription Program, and
to monitor the rate of adverse drug incidents associated with the program and patient’s level of satisfaction to the program.
Methods.
Repeat prescription helps to expand the servicing capacity of the healthcare system, and increase convenience and
accessibility for patients. Known drawbacks of repeat prescription are compromised quality on patient care and failure to
monitor the effectiveness and safety of the prescribed medication regime.
In our study from 2004 through 2008, a pilot program of repeat prescription was introduced to enable better monitoring of
clinical outcomes and drug use safety. Under the program, chronic patients who had fulfilled a specified set of inclusion
criteria were allowed for repeat prescription. The inclusion criteria were a number of clinical assessments that indicated
that the chronic illness/condition was stable, and they were decided by the Clinical Practice Improvement Team of our unit
after repeated team meetings with doctors, nurses and dispensers.
After joining the program, patients would be given a unique identification number for future retrieval of data including
name of patient, Hong Kong identity number, type of clinical conditions and drug name and duration to be restocked. They
were then reviewed alternately by nurse and doctor in the clinic, at the 12th and 24th weeks respectively, for assessment
and restocking of medications. Those found to have unsatisfactory control would be withheld from the repeat prescription
program until stabilized.
Clinical parameters e.g. mean blood pressure and cholesterol level and adverse drug incidents were followed
longitudinally through the study and compared before and after repeat prescription. Individual chart review was performed
to collect clinical data and questionnaires, to assess patient’s level of satisfaction to the program.
Results.
During the study period, 304 patients were studied, 161 (53%) were male; and mean age of patients was 58.4 ± 8.3 years.
Over eighty percent of patients (255) had one chronic illness only. The most common condition was hypertension; and the
mean duration of disease was 9.0 ± 5.0 years (1.7 – 33.0 years). The mean duration of repeat prescription was 1.7 ± 1.0
years (range 1.2 - 52.8 months). After repeat prescription, there was a small but statistically significant decrease in mean
systolic blood pressure (-2.2 mmHg, p=0.01) and diastolic blood pressure (-2.2 mmHg, p=0.0003), and no change in
cholesterol level (p=0.30). No adverse incident was reported. 99% of patients were satisfied or highly satisfied with the
program.
Conclusions.
After implementation of the pilot program of repeat prescription, we found no deterioration in clinical outcomes of patients.
There were no adverse drug incidents reported. Patients were highly satisfied with the program.
0057
Investigation and Prevention of adverse drug events in a primary care setting in Hong Kong
Ka Wae, Tammy Tam, Kon Hung Kwok, Kwok Keung Ng, Chiu Yee, Luke Tsang
Professional Development & Quality Assurance, Department of Health, Hong Kong
Objective.
To investigate the type and nature of adverse drug events and potential adverse drug events captured by the incident
reporting system, in order to guide the implementation of strategies to promote drug use safety for patients in a primary
care setting.
Methods.
The incident reporting system was established in four primary care clinics in May 2006, under which any adverse drug
events and potential adverse drug events detected in daily clinical practice were reported with an incident report form,
which was then submitted to the doctor in charge of the incident reporting system, for data entry and analysis.
Data collection included patient’s demographic data, date of drug event, identity of the detecting and reporting subject,
and classification, summary and severity of the drug event. The severity level of drug event was graded from significant,
serious, life-threatening to fatal level.
Series of clinic meetings were held beforehand to introduce the objective of the incident reporting system and the method
of reporting; there was a 1-week pilot reporting period before commencement of the system. Name of the reporting
subject was kept anonymous.
From May 2006 through November 2010, interval data review was presented among team members every three-monthly.
Any sentinel event for reporting would initiate immediate clinic meetings to discuss remedy strategies.
The whole set of data collected through the study period was analyzed for the type and nature of events. From the study
findings, different improvement strategies were proposed and implemented to promote drug use safety.
Results.
During the study period, out of the 3,900,000 prescription items, 38 potential adverse drug events and 142 adverse drug
events were captured by the incident reporting system.
Of the 142 adverse drug events reported, 9 (6.3%) were classified as preventable and 133 (93.7%) as non-preventable.
They were mainly caused by allergic reactions and side effects of medications. Of these, 119 (83.8%) of them were
graded as significant in severity, 22 (15.5%) were serious, 1 (0.7%) was life-threatening and none was fatal. One example
of the serious drug event was related to over-dosage of a tri-cyclic anti-depressant resulting in sinus tachycardia and high
blood pressure; and the life-threatening event was caused by oversight of previous allergic history to a non-steroidal antiinflammatory drug.
Of the 38 potential adverse drug events noted, 4 (10.5%) were categorized as non-intercepted and 34 (89.5%) as
intercepted, mostly detected by dispensers. Most of the incidents were due to wrong prescription of drug or dosage
problem, confusion of drugs with similar names, resulting in dispensing of wrong drugs, omission of drug items, and
incorrect information on drug labels.
After analyzing the results, different improvement strategies were proposed and implemented to promote drug use safety,
including drug information poster in consultation rooms, drug alert stamp on medical record, drug allergy mug for doctors,
drug allergy card for patients, computerizing drug allergy registries in dispensary record, reminder poster of drugs with
similar names in dispensary, and multiple checking in dispensing of medications.
Conclusions.
Adverse drug events were largely related to allergic reactions and side effects of medications. Potential adverse drug
events were mostly due to wrong prescription of drug or dosage problem, confusion of drug with similar names, omission
of drug items or wrong information on drug labels. Corresponding improvement strategies included drug information
poster, drug alert stamp, drug allergy mug, drug allergy card, computerization of drug allergy registries, reminder poster of
drugs with similar names, and multiple checking in dispensing of medications.
0062
Work analysis of general ward nursing care and nursing assistant in a medical center of south Taiwan.
FU MEI Hsu, SHU HUI Hu, YU LING HSU, CHUN HUI HSIAO
CHI MEI MEDICAL CENTER, Tainan shien, Taiwan
Objective:
This study is to investigate the average working hours of ward attendants and ward assistants in 15 units of general wards
and a total of 99 nursing activities of a medical center in south Taiwan via self recording and observation methods. The
purpose is to understand the average working hours and frequency required of nursing care activities,, and calculate the
average hours of nursing care, complete the daily nursing statements to understand the percentage of time required in
different nursing activities, in order to streamline work procedures, improve working efficiency; and established day-shift,
evening-shift and night-shift nursing time allocation, including direct care, indirect care, associated care and personal time
to serve as the basis for human resource allocation.
Methods:
th
st
The research was started from the 97 year of the Republic Era 1 March to 31th March, with a total of 30 days. The
subjects involved 15 units from internal medicine, surgery, obstetrics and gynecology and pediatrics department, with 47
self-recorded nurses participated. The research was done through an observation documentation made by a supervisor
and deputy supervisor. Head nurse from those 15 units were recruited for orientation to achieve consistency, content
validity and expert validity of the collected data.
Results:
The results showed there are 69 activities of direct function in general ward while 19 activities of indirect care and 11
activities of other individual activity). An average of 3.4 hours nursing care daily, with variability among different ward and
different specialist.
Conclusions:
In addition to establish the definition of nursing activities, technical standards and working hours of scoring the test, this
research also enhance our understanding to the content and time allocation of the nurses work, in order to make a
reasonable adjustments in manpower, streamlining the work processes, and to achieve a full play of human performance.
0063
The Prediction of Health Care Outcomes after Total Hip Replacement using the Charlson Comorbidity Index in
Korea
3
1
2
2
Hyeyoung Seo , Won-Ho Choi , Seok-Jun Yoon , Hyeong-Sik Ahn
1
Ewha Women University Medical Center, Seoul, Republic of Korea
2
Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
3
Graduate School of Public Health, Korea University, Seoul, Republic of Korea
Objective: The aim of the present study is to examine the confidence level and validity of the Charlson Comorbidity Index
(CCI) based on medical records data and administrative claims data for patients undergoing total hip replacement.
Methods: We analyzed data from patients who received total hip replacement from January 2003 to December 2006.
Agreement between the comorbidities of the medical record and claims data was analyzed using the Kappa value. To
compare the predictability for the outcome of 1-year mortality, length of stay and cost between medical records data and
claims data, multiple logistic regression and multiple regression which were adjusted for sex and age were cross used
2
and then C statistic or R were used as standards for comparison.
Results: One-year mortality was analyzed to be 0.664 and 0.726 of the C-statistic, based on medical records and
administrative claims, respectively. The predictability of mortality using claims data was similar to that estimated using
medical records data. As a result examining the predictability of length of stay and medical cost, their coefficients of
determination (R²) were relatively low in both cases: 1.81% for the medical records data, 3.16% for the claims data and
18.42% for the medical records data and 17.49% for the claims data respectively.
Conclusions: The 1-year mortality index of total hip replacement patients, which was obtained utilizing CCI, was similar
when using either medical records or administrative claims data. This suggests the possible usefulness of claims data
based CCI in health service research area. The predictabilities of length of stay and cost, however, were limited and
therefore should be carefully analyzed before use. Since claims data are relatively easy to collect, additional studies and
methodological improvements using claims data may be a fruitful direction of future research for many diseases.
0065
Effect of the Innovative Portable Illuminating Oral Cleaning Suction Device on the Improvement in Patient Oral
Cleaning
YI TSENG TSAI, CHIN HSUAN WU, Hwey Fang LIANG, PEI CHIEN LU
Chang Gung Memorial Hospital, Chiayi, Taiwan
Abstract
The common treatment for patients with head and neck cancer is chemotherapy in combination with radiotherapy.
However, patients often suffer inflammation, ulcer, or bleeding due to changes in oral mucosa. The WHO mucosa rating
scale was used to investigate 73 patients with head and neck cancer receiving chemotherapy in combination with
radiotherapy from January to December, 2010 at the hospital. Fifty-nine patients experienced change in oral mucosa, and
the incidence rate was 81%. The oral mucosal change of a total of 52 patients was above level 2 (high-risk group). It was
found that the causes for severe oral mucosal damage included patients’ low awareness of oral care, lack of appropriate
oral cleaning tool and oral care health education manual. The purpose of this project was to increase head and neck
cancer patients’ awareness of oral care and to improve oral cleaning tool to increase the implementation rate of oral care.
The solutions are included: 1) to hold oral care health education classes; 2) to innovate “portable illuminating oral cleaning
suction device” and to produce “oral care” health education manual. After this, patients’ oral care awareness was
increased from 75% to 95%, oral cleaning implementation rate was increased from 65% to 90%, and overall patient
satisfaction increased from 3.2 to 4.8.
Purposes
Increase patients’ oral care awareness to 85% and to increase the oral cleaning implementation rate to 90%.
Method
Fifty-two head and neck cancer patients whose oral mucosal change was above level 2 after receiving chemotherapy in
combination with radiotherapy. “Scale on Head and Neck Cancer Patients’ Oral Care Awareness after Receiving
Chemotherapy in Combination with Radiotherapy” and “Oral Care Implementation Registration Form” were used as
assessment tools. The results indicated that the patient awareness was 75% and the oral cleaning implementation rate
was 65%. The research team developed the “portable illuminating oral cleaning suction device.” The two-head cap and
PVC transparent tubes were used to assemble the device. Non-return valve was used to design the water and gas flow
paths. The squeezing of manually operated rinsing bottles can discharge the water and gas. Teeth cleaning sponge stick
and LED lights were installed at the front end near the patients. The water ejected during the squeezing of the rinsing
bottle infiltrated into the teeth cleaning sponge stick to wash oral mucosa. For postoperative patients who could not easily
open their months, the teeth cleaning sponge stick would be replaced by No. 18 soft intravenous catheter needle to wash
oral mucosa and prevent it from being hurt. The suction tube for dental use was installed at the end of the suction bottle
tube to attach to interior mucosa. Based on the principle of vacuum aspiration, after the air and water were discharged
from the suction bottle, the original air would return to the rinsing bottle to enable the re-operation of the squeezing and
washing. It was easy to operate the device and the device was a portable personal oral cleaning tool.
Results
Patients’ oral care awareness was increased from 75% to 95%, and the oral cleaning implementation rate was increased
from 65% to 90%. The satisfaction with safety, convenience, utility, comfort level, and appearance was investigated, and
the overall patient satisfaction increased from 3.2 to 4.8 (5-point assessment scale).
Conclusions
Effective oral care increase patients’ oral comfort. The affordable, safe, easy-to-operate “portable illuminating oral
cleaning suction device” which meets patients’ needs, and its dual function of washing and suction can satisfy patients’
need for oral cleaning to further increase nursing care quality.
0072
Improving quality of care by implementing a consultant-delivered service
Surayne Segaran, Robert Jones, Ruaraidh MacDonagh
Musgrove Park Hospital, Taunton, Somerset, UK
Objective
To determine if increased consultant presence and input in the emergency setting can decrease length of inpatient stay
and improve the quality of service delivery in the urology department of a district general hospital in the United Kingdom.
Methods
Prior to 2010 there were 4 full-time consultant urologists in our department, each working 11 4-hour sessions weekly. In
January 2010 a pilot restructuring of service was carried out, with emphasis on reducing the elective workload of
consultants during their week on call. A locum consultant was appointed to facilitate this, who has since been appointed to
a substantive post. The duty consultant now has no scheduled commitments other than two clinics, which are in the
afternoon, ensuring that mornings are free for a consultant-led ward round. In addition, the duty consultant deals with all
acute inpatient referrals, leads clinical meetings (X-ray and multidisciplinary), provides advice and opinions to other
specialties and general practitioners, and performs acute operating. Daily supervision and teaching of the junior clinicians
is also the responsibility of the duty consultant. A rolling system of cover among the other 4 consultants was put in place
to prospectively fulfil the remaining elective commitments.
Data on length of inpatient stay and bed occupancy during two similar periods of the year before and after the change in
rota was obtained from Hospital Information Services. Prospective data collection was carried out to look at the number of
in-hospital referrals and the proportion of these seen within 24 hours, as well as the presence of the consultant on the
ward round.
Results
After implementation of the revised rota, 87% of ward rounds were led by a consultant, an increase from approximately
20% prior to the change.
Mean length of stay for all urology patients decreased from 4.5 to 3.8 days. Emergency admissions showed a greater
decrease (6.2 to 5.7 days) compared to elective admissions (2.7 to 2.4 days). In addition to this, 94% of inpatient ward
referrals from other specialties were seen by a consultant Urologist within 24 hours of referral. There was a reduction in
occupied bed days from 372 to 344 over comparable 2-month periods in consecutive years.
There is increased opportunity for teaching on ward rounds, as well as closer supervision of junior staff, particularly
Foundation doctors who previously had little daily contact with consultants. The Specialty Trainee is typically able to go to
theatre earlier and therefore gains valuable operative experience.
Conclusions
Our experience shows that implementing a consultant-delivered service into the on-call urology rota can have a positive
impact by decreasing length of patient stay, providing safe and high-quality care, as well as increasing opportunities for
supervised and structured teaching.
0077
A Fuzzy-Rule-Based Approach to Fall Detection
1
1
2
2
Mu-Chun Su , Xing-Han Wu , Chia-Huang Chang , Pa-Chun Wang
1
2
Department of Computer Science & Information Engineering, Taoyuan, Taiwan, Quality Management Center, Cathay
General Hospital, Taipei, Taiwan
Objective: The objective of this paper is not only to detect falls but also to identify the directions of falls based on a triaxis accelerometer. The proposed fall detection system incorporated with a ZigBee-based location system can quickly
locate the position where a fall happens such that a quick and effective response can be issued.
Methods: The accelerometer module uses a tri-axial ADXL330 accelerometer and a CC2430 ZigBee microcontroller to
detect falls. In order to increase the degree of error tolerance and decrease the miss-classification of the activities of daily
living, the fall detection system adopts a fuzzy system to implement the core decision module of the fall detection system.
The fall alerts were transmitted to a PC-side receiver via a ZigBee wireless module. The fall detection system was used
on 7subjects to test simulated falls and activities of daily living.
Results: When a subject falls, the fall detection system can effectively detect his or her falls and response the location of
the subject, For the time being, the sensitivity rate of right, left, back and front fall was 80%, 76%, 100% and 100%,
respectively. In addition, the system would identify the not-real fall event with specificity of 100%.
Conclusion: The fall detection system shows good sensitivity and specificity to distinguish falls from activities of daily. By
using this system, it could simultaneously detect falls and determine the locations of patients. In addition, it could be tied
in with the investigation into the hospital patient falling incident and assess the detection applying in the effectiveness of
falling prevention events.
0080
A multi-level of Patient Safety Culture Effect on Safety Performance－The Case of Nurse
1
2
1
1
Cheng-Chia Yang , Yi-Hsuan Lee , Suh-Er Guo , Mei-Fen Huang
1
2
Kuang-Tien General Hospital, Department of Administration, Taichung County, Taiwan, National Central University,
Department of Business Administration, Jung-Li City,Taoyuan, Taiwan
Objective: In recent years, patient safety has been concerned in medical care of different nations. Many researches have
probed into the factors of medical safety, and found risks and negligence in current medical environment. In recent years,
many researches have developed scales to measure patient safety culture. Past scales or studies on safety culture are
mostly based on single-level measurement. Zohar(2005) suggested that safety culture should be multilevel. Different units
have different interpretations on organizational policy, and organizational and unit climates have mutual influence on each
other. Medical industry involves the distinctness and profession. Priority of safety culture in different professional units in
hospitals would be different. Information and regulation for personal safety behavior are from the units which undertake
the organizational policy. This study intends to probe into the possible correlation between the three. The research
purposes are below: propose multilevel scale on safety culture in medical industry, study the relationship between
organization-level safety culture, unit-level safety culture and individual safety performance.
Methods: This study refers to the scale of safety culture revised based on SCS, PSCHO and SAQ developed by foreign
researches. Organization-level safety culture refers to employees’ perceived organizational involvement in safety and
commitment to safety, and it is measured by organizational management and commitment. Unit-level safety culture refers
to employees’ perceived unit’s safety process planning and management. Communication, inspection management and
accident management are used to describe individuals’ perception of unit safety culture. Safety performance is to
measure task-related behavior. Individual safety behavior is measured by safety compliance, safety participation and
safety behaviour.
Results: This was a cross-sectional study, and distributed 700 questionnaires to nursing staffs in four regional hospitals
in Taiwan. A total of 363 valid samples were returned; the valid return rate was 51.8%. Confirmatory factor analysis (CFA)
was performed to test the factor structure. The construct composite reliability was significant, and factor loading was >0.5,
thus indicating an acceptable model fit. We found organization-level safety culture (γ11=0.96) positively influences unitlevel safety culture. It means that higher value of organization on safety culture has more positive influence on unit
supervisors’ creation and effect of safety culture. Unit-level safety culture (γ13=0.55) positively influences safety
performance, indicating hat higher safety culture will more positively influence employees’ task-related safety behavior.
Hypothesis of organization-level safety culture on safety performance is insignificant. However, according to the path,
organization-level safety culture indirectly influences safety performance by unit-level safety culture. Indirect effect is 0.53.
The result shows that unit-level safety culture is the mediating variable between organization-level safety culture and
safety performance.
Conclusions: This study finds that unit culture, as compared to organizational safety culture, is more influential on
employees’ safety behavior. It shows that single level analysis is not suitable for evaluation of safety culture. Although
senior management values and promotes safety, lower management’ implementation of safety policy and information
communication will influence the unit members differently. Influence of lower management is the most significant. Past
researches on social cognition suggested that with the same information, the individuals would have different cognitions.
When the individuals receive new information, they would modify the previous judgment. Thus, the policy passed from top
to the bottom will rely on lower management’s execution of policy and process, which would result in a kind of
interpersonal network of social interaction. Lower management’s policy execution will moderate the final implementation
result. In the process of top-down passage pf policy, the same policy would be changed, and result in employees’
inconsistency of information in organization. Thus, analysis on safety culture formation should be based on different levels.
0084
Surveillance of Abnormal Liver Function among Chronic Hemodialysis Patients: A Single Hospital Experience in
Southern Taiwan
Te-Chuan Chen, Chun-Jen Lai, Ku-Chung Wang, Chien-Te Lee
Chang Gung Memorial Hospital, Kaohsiung Medical Center; Chang Gung University, College of Medicine, Kaohsiung,
Taiwan
Objective:
We investigate the incidence of abnormal liver function on chronic hemodialysis patients and correlate with age, gender,
comorbidity and rhythmic change of weather and temperature.
Methods:
Routine monthly liver function tests in a study period of 5 years of chronic hemodialysis population were reviewed.
Abnormal liver function (ALF) is defined as alanine aminotransferase (ALT) > 40 U/L. We then calculated the percentage
of ALF every month. Their demographic data such as age, gender, diabetes mellitus were reviewed and recorded.
Patients were grouped as hepatitis B (HBV), hepatitis C (HCV) and non-hepatitis (NHV). To investigate the influence of
age, patients were further divided into ages less than 49 years; between 50 to 64 and those older than 65 years. The
mean monthly temperature (MMT) is defined as the average of the highest and lowest daily temperature in the month by
the forecast reports. All data were analyzed by using SPSS (17.0 for Windows) software.
A p value less than 0.05 is considered statistically significant.
Results:
A total of 2003 ALF were included for analysis. The distributions in various groups were 15.2 % in HBV; 33.8 % in HCV
and 51 % in NHV group. And 15.9 % of abnormal tests were observed in diabetes. Age, gender and associated diabetes
all affected the incidence of ALF in HBV group (all p < 0.05). In patients with HCV, incidence of ALF differed significantly
among various age groups (p<0.001) but was not affected by gender and diabetes. The highest incidence of ALF was
observed in the spring. Furthermore, there was significant correlation between incidence of ALF and season change in
HBV and NHV (both p<0.05) but not in HCV group. A significant parallel association between the incidence of ALF and
MMT were observed in all three groups.
Conclusions:
Our retrospective analysis revealed that incidence of ALF was a simple and effective method to monitor underlying liver
disease and facilitate infection control in hemodialysis units. Patients with either HBV or HCV had more frequent ALF than
NHV. Demographic data affected the incidence of ALF among chronic hemodialysis patients. In a longitudinal analysis,
incidence of ALF was noted more frequently in the spring and correlated with rhythmic alteration in temperature.
Key words: abnormal liver function test; age; gender; diabetes mellitus; seasons; weather change.
0086
Analysis of Actions Following Adverse Patient Safety Events: Lessons Learned for Preventing Reoccurrence
Patricia Hunt, Jessica Jaiven, Georgene Miller
Provincial Health Services Authority, Vancouver, B.C., Canada
Objective: This project describes key learning and strategies for preventing reoccurrence from analysis of critical patient
safety events (CPSE) experienced by a large multi-agency health care organization in British Columbia Canada –the
Provincial Health Services Authority--which provides specialized and tertiary health care services to some of the most
vulnerable populations in the province. In our efforts to be a highly reliable organization, we analyze recurring themes in
the actions following critical patient safety events to help a) identify areas of continuing vulnerability and b) target priority
action on commonly reoccurring safety concerns and root causes.
Methods: We conducted a retrospective analysis of all preventable critical patient safety events – level 4 and 5
(significant patient harm and/or death) that underwent a formal review/Root Cause Analysis (RCA) process over two
years (09/10) across the health authority (5 agencies). Data was taken from the incident reporting system, completed
CPSE reports and interviews with quality and risk management leaders involved. Actions were categorized and grouped
in 5 themes. Frequencies of categories by each event were counted once. Proportions of total CPSE with an action for
each theme were calculated.
Results: A total of 85 critical events with completed reports that occurred during 2009 and 2010, were reviewed.
Three dominant themes emerged in the actions analysis (listed from most to least prevalent): 1) Standard Operating
Procedures (36%) e.g. Checking/processing of orders; Medication “rights” and reconciliation; Development/revision of
policies and protocols. 2) Education and Training (19%) e.g. Assessment and Diagnostics, Team member roles and
responsibilities; Management/Responsiveness to deteriorating patient conditions. 3) Communication Promotion (28%) e.g.
Stop the line, Transfers/Patient Hand-offs, Team communication. Additional emerging themes: Access/availability to
Services and Technical Performance (e.g. Systems/job task re-design, equipment).
The analysis has spearheaded: 1) Prioritizing and taking targeted actions on those recommendations that are commonly
re-occurring through specific and focused patient safety projects, e.g. BC Cancer Agency: Intensive process flow mapping
and mistake proofing for eliminating mistakes with processing of physicians’ orders; BC Women’s and Children’s
Hospitals: Team building and communication strategies including SBAR and Stop the Line. 2) Further training/skill
building with event review leaders and participants on developing stronger actions that translate into demonstrable safety
changes. 3) Mobilizing stronger system level actions: a) Further efforts promoting safety culture and non-punitive
response to error including culture measurement and follow-up strategies; b) Promotion of near miss and event reporting;
c) Team work; d) Safety rounds/Executive walk-arounds and audits; e) Use of checklists and read back systems, e.g.
Safe surgery and Patient Handovers checklists; f) Medication reconciliation; g) Leader capacity/ expertise development in
RCA and Mistake Proofing methodology.
Conclusions: Our study offers a different view and contributes to the literature by focussing trending on the
recommended actions arising from events rather than on less informative error categories. It enables more insight
regarding opportunities that enhance learning, reduce event reoccurrence and improve patient safety. It has provided
clues and direction regarding the need for more proactive risk assessments and failure mode effects analysis to prevent
events where possible or mitigate patient harm. Continued trending and analysis is required in building on a body of
evidence to demonstrate that actions are truly effective in reducing/eliminating risk of recurrence.
0088
Seamless and Effective Stroke Rehabilitation Program in Tung Wah Eastern Hospital
Wai Yin Kevin Tsang, SW Tang, KP Leung
Tung Wah Eastern Hospital, Hong Kong
Introduction
Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional
disability. A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to
post-acute rehabilitation after a stroke. Improved functional outcomes for patients contribute to patient satisfaction and
reduce potential costly long-term care expenditures.
Objectives
(1) To describe the structured multidisciplinary in-patient stroke rehabilitation program that help stroke patients achieve
maximum functionality and independence
(2) To identify the important components of a cost effective in-patient stroke rehabilitation program
(3) To develop a service model that provides seamless bridging to community-based rehabilitation services to facilitate
community reintegration.
Methodology
Post-acute stroke patients after being stabilized in acute hospital (PYNEH) were transferred to TWEH for stroke
rehabilitation which was delivered in a subspecialty setting in specific wards. A coordinated multidisciplinary team consists
of a rehabilitation medicine specialist, nurse, physiotherapist, occupational therapist, speech therapist and social worker
to offer organized in-patient stroke rehabilitation care. Program components include multidisciplinary evaluation, goal
setting and specific treatment programs in each specialty area and with particular emphasis on the early participation of
family/caregivers in the whole treatment process to promote partnership. After completing the in-patient rehabilitation
program, patients were transited to TWEH Integrated Community Rehabilitation Centre (ICRC) to continue community
phase of rehabilitation.
Specific and distinctive components of stroke program include:
-
Early multidisciplinary assessment within 2 days of admission
-
Use of well-validated, standardized instruments in assessment and outcome measure--Functional Independence
Measures (FIM): the most commonly used outcome measure for assessment of functional status with our data
submitted to Uniform Data System for Medical Rehabilitation (UDS) in USA
-
weekly multidisciplinary case conference with the involvement of family/caregivers in care education, setting
treatment goals and decision making
-
specific rehabilitation technology: e.g. Body weight support treadmill system, balance trainer, virtual reality
rehabilitation, robotics etc,.
-
Family education and caregiver training: provided in an interactive format with empowerment of their knowledge
and technique, and thorough communication on outcome expectations and their role in the rehabilitation process.
-
early introduction of discharge planning and community resources through social worker interview, booklets and
VCD to family/caregivers.
-
seamless bridging with ambulatory rehabilitation training: pre-discharge assessment in ICRC and start
ambulatory training within 1 week after discharge
Results
A total of 802 patients were entered into our stroke program in 2007 and 2008. The mean admission FIM score was
62.4(other clusters: 62.5) and mean discharge FIM score was 74.8(other clusters: 73.8). Mean FIM score gain was 12.4
(other clusters : 11.2; +10.7%)while the mean FIM gain/week was 5.65.(other clusters: 4.15; +36%). The mean length of
stay per patient in TWEH was 19.7days (other clusters: 30.1days). An average of 4190 bed days per year were saved for
stroke patients in TWEH when compared with other clusters and the cost saved was $12,570,000 per year.
Conclusion
The Stroke Rehabilitation Program in TWEH demonstrates an effective and outstanding model of stroke rehabilitation
care with significant cost saving and better rehabilitation outcome.
0089
Prioritizing interventions against medication errors – the importance of a definition
Marianne Lisby, Louise Pape Larsen, Ann Lykkegaard Soerensen, Jan Mainz
Aarhus University Hospital, Aarhus Sygehus, Aarhus, Denmark
Objective: To develop and test a restricted definition of medication errors across health care settings in Denmark
Methods: Medication errors constitute a major quality and safety problem in modern healthcare. However, far from all are
clini-cally important. The prevalence of medication errors ranges from 2-75% indicating a global problem in defining and
measuring these [1]. New cut-of levels focusing the clinical impact of medication errors are therefore needed.
Development of definition: A definition of medication errors including an index of error types for each stage in the
medication process was developed from existing terminology and through a modified Delphi-process in 2008. The Delphi
panel consisted of 25 interdisciplinary experts appointed by 13 healthcare-, professional- and scientific organizations in
Denmark.
Test of definition: The definition was applied to historic data from a somatic hospital (2003; 64 patients) [2] and further,
prospectively tested in comparable studies of medication errors in a psychiatric hospital (2010; 67 patients) and in nursing
homes (2009; 33 patients). Finally, it was tested in a study of prescribing errors in a somatic hospital (2010; 108 patients)
The same data collection methods (chart review; review of electronic drug order system; direct observation; unannounced
control visit), denominator (opportunities for errors) and the same severity scale to assess the potential clinical
consequences (potential fatal, -serious, -significant and non-significant) were used in all four studies[2] to measure
prevalence’s reflecting the impact of the definition. The overall prevalence of medication errors was compared between
the somatic hospital (2003), the nursing homes and the psychiatric hospital whereas comparison of prescribing errors
included all four clinical settings.
Results: Definition: The expert panel reached consensus of the following definition “An error in the stages of the
medication process - ordering, transcribing, dispensing, administering and monitoring the effect - causing harm or
implying a risk of harming the patient”. In addition, consensus for 60 of 76 error types covering all stages in the medication
process was achieved.
Test of definition: The definition of medication errors corresponded to the levels potential fatal and potential serious in the
severity scale [2]. After application of the definition the overall prevalence of medication errors was 144/1.942 (7.4%) in
the retrospective test and in the prospective studies 100/1.249 (8.0%) in the psychiatric hospital and 83/1.134 (7.3%) in
nursing homes. Similar patterns were seen when comparing the occurrence of prescribing errors: 52/991 (5.3%:CI95%:
3.9-6.8) retrospective test; 23/510 (4.5%: CI95%: 2.9-6.7) psychiatric hospital; 100/872 (11.4%:CI95%: 9.4-13.8) and
finally 53/1.437 (3.7%: CI95%: 2.8-4.8) in the somatic hospital. Further analysis of prescribing errors in the somatic
hospital indicated paracetamol, opioids and antibiotics as the most frequently involved drugs and ordering an
unnecessary drug or an inappropriate drug as well as discrepancies between drug orders constituted the majority of
prescribing errors when defined as errors with potential for harm.
Conclusion: A definition restricted to the potential clinical impact of medication errors appears to be a reproducible
method across healthcare settings detecting almost identical prevalence’s in overall studies of medication errors and in
studies of prescribing errors. In addition, it contributes to identify medication errors related to high-risk processes and
drugs. The definition can therefore be considered as a relevant tool for decision makers in modern healthcare to prioritize
interventional strategies.
1) Lisby M, Nielsen LP, Brock B, Mainz J: How are medication errors defined? A systematic literature review of definitions
and characteristics. Int J Qual Healthcare 2010; Vol. 22 (6) pp. 507-518
2) Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency type and potential Int J Qual Healthcare
2005; Vol. 17 (1) pp.15-22
0091
Access Block: The Application of Variability Management in Emergency Department
Eddie YUEN, Richard SD YEUNG, Jimmy TS CHAN
Alice Ho ML Hospital, Tai Po, Hong Kong
In this presentation, we will describe the use of Variability Management in enhancing patient flow and the application of
Variability Management in Emergency Department of a local acute hospital.
Introduction
Access block has been a worldwide problem in both developed and developing countries. The Joint Commission
International has published literature in managing patient flow in hospital.
We adopted a novel 'Owl' ward strategy to admit emergency patient during the night time.
Night Emergency Medicine Ward (Owl ward) was set. It served to enhance the efficiency and effectiveness of emergency
healthcare, intercede and support Doctors Work Reform (DWR) in reducing the night activity and manpower of medical
specialty, such that manpower and resources are better targeted to patient care during the daytime. The operative model
of OWL ward is to diverted acute medical admission from 21:00 to 09:00 the next day (night time) to the OWL ward. It is
led and run by emergency physician.
Objective
1.
Assess the impact of OWL ward on the reduction in acute medical admission during night time.
2.
Assess the impact to the medical & A&E department, through analysis of the overall emergency medical
admission and the number of bed alert (access block) in A&E department.
Methodology
1.
Data for acute medical admission of pre and post OWL period were compared, extracted from AEIS and CDARS.
The studied periods were Dec 2008 to Nov 2009. Data from Dec 2007 to Nov 2008 were compared.
2.
Data included absolute number of admission during 21:00 to 09:00, occupancy rate of medical department (at
midnight) and the number of bed alert (access block).
3.
The reattendance rate at A&E and readmission to medical ward were also analyzed.
Results
1.
The admission to acute medical ward during 21:00 to 09:00 reduced by 46% after the implementation of OWL.
2.
An average of 9.8 cases was admitted OWL during 21:00 to 09:00
3.
Overall emergency medical admission dropped by 31.2%.
4.
A lower bed occupancy rate in medical department was observed.
5.
Dramatic drop in the number of bed alert was seen.
6.
No increase in A&E reattendance or readmission to medical ward was noted during the studied period.
7.
No complaint was noted from the implementation of OWL.
Conclusion
The implementation of OWL ward has showed to be an effective and safe model in reducing night acute medical
admission and the overall acute admission to the medical department. It enhances the healthcare provided through
effective system and better manpower matching.
0094
Provision of X ray portable service on Public Holiday/ Statutory Holiday/ Sundays in a Hong Kong regional
Hospital
Sin Yee Monica CHU, Suk Hing Sarah Ng, Amy Leung, Louisa Leung
Hospital Authority, Hong Kong SAR, Hong Kong
Objective:
Reduce the average lead time of portable x ray service in Tuen Mun Hospital (TMH) from 118 minutes to 106 minutes and
reduce the number of urgent portable cases of lead time longer than 120 minutes from 52% to 25% by 1Q of 2011.
Methods:
Portable lead time was defined as the time of request to the image verified on workstation.
Members performed Gemba walk and on site data collection. The current performance of Y was obtained through
meeting with department head. SIPOC was drawn and define the process map of portable x ray.
Data collection sheet A was designed according to the process map.
E-mail was disseminated to particular radiographers and clerical staff to inform them of the project and how to collect 24
hour data on 28 Nov 10. Run chart was plotted. Root cause analysis was performed with key root cause (x) identified. .
Small and regular batching was proposed. Force field analysis was performed.
On 8 Dec 10, focus group sharing was made with Radiographers on the implementation of small regular batching.
Pilot run was performed on 25 Dec 10. The average and maximum L/T for both 28 Nov 10 and 25 Dec 10 was compared.
Guideline was issued. Andon system was introduced to remind radiographer occupied in operating theatre would aware of
the long lead time of the backlog portable request.
Voice of stakeholder was sought. Telephone conversation was made with Department Operation Manager of operation
theatre on 26 Jan 11. All unit heads were informed of the new batching system on 29 Jan 11 via intranet.
Full implementation was scheduled on 3 Feb 2011.
Control measures after implementation
Batching time of portable x ray was logged. Monthly review would be done by Senior Radiographer.
Exception case (portable exam L/T beyond 240 mins) report will be done monthly for the first three months after
implementation.
Results
1.
There was a significant improvement in total L/T.
2.
The total L/T had been reduced from 111.9 minutes to 86.4 minutes in average.
3.
The % of cases having lead time larger than 120 minutes was reduced from 52% to 12% (target set at 25%).
Conclusions
Small and regular batching of 2 hour interval was effective in reducing the total lead time of portable x ray service
significantly.
The project achievement was better than expected.
0096
Prophylactic Antibiotics Uses in Thyroidectomy and Risk Factors for Surgical Site Infection
hsiuju Jen, Yin-Yin Chen
Far Eastern Memorial Hospital, Taipei, Taiwan
Background:
Surgical site infection is one of the most common types of nosocomial infection and an important factor in increased
mortality and medical costs. The effectiveness of prophylactic antibiotics use on the wound site of thyroidectomy merits
further examination.
Objective:
Compare how prophylactic antibiotics use or non-use in thyroidectomy influences the chance of surgical site infection,
average length of hospital stay and average medical costs.
Methods:
A observation study was undertaken with patients undergoing thyroidectomy at the general surgery ward of a medical
center between 2007 and 2008 as the subjects. The subjects were divided into two groups with the first group consisting
of patients that received prophylactic antibiotics 30 minutes before thyroidectomy between January 1, 2007 and October
31, 2007. For this group a retrospective review of the patient charts and reports was carried out. The second group
consisted of patients that did not receive prophylactic antibiotics 30 minutes before thyroidectomy between November 1,
2007 and October 31, 2008, in line with the new antibiotics policy of the research hospital.
Results:
A total of 310 subjects were enrolled in the study and surgical site infection did not occur in either group (p=.694). There
were 15 patients (4.8%) that received a course in antibiotics after surgery with 6 (40%) showing signs of surgical site
infection (swelling) (p=.001) though there was a significant link to an existing diabetic condition (p=.010). The risk factors
in post-surgical antibiotics use included diabetes (P=.032), surgery duration in excess of 2 hours (p=.028), drainage pipe
being left in place at the surgical site (p=.032) and drainage pipe being left in place for more than 2 days (p=.028). When
prophylactic antibiotics was not used before surgery, there was a significant reduction in the average length of hospital
stay (p=.001) and medical costs (p=.001). When the length of hospital stay exceeded 4 days, the cost of post-operative
antibiotics increased by $5,850 and medical costs increased from $32,436 to $63,895 as well. If the length of hospital day
was kept to within 4 days and post-operative antibiotics used then there was no significant difference in drug and medical
costs.
Conclusion:
The non-use of prophylactic antibiotics before thyroidectomy does not increase the risk of surgical site infection.
Key Words: Prophylactic antibiotics, surgical site infection, thyroidectomy.
0098
Effective media advocacy strategies for quality and safety professionals.
Hinchcliff, R; Greenfield, D; Westbrook, J; Braithwaite, J
Reece Hinchcliff, David Greenfield, Johanna Westbrook, Jeffrey Braithwaite
Australian Institute of Health Innovation, Sydney, NSW, Australia
Objective:
To provide quality and safety professionals with recommendations to assist their engagement in effective media advocacy.
Methods:
We performed a content analysis of articles discussing medication errors published in the ten most widely read Australian
daily newspapers between January 2005 and January 2010. Key features of this coverage were recorded, including the
role of leading commentators and the prominence of different themes and issues. In addition, a literature review was
undertaken to identify media advocacy strategies that have been effectively employed in different fields of health policy.
This involved an interrogation of relevant material published between 2000 and 2010 in the Medline and Web of Science
electronic bibliographic databases. The results were combined into a series of best practice recommendations for quality
and safety professionals wishing to conduct media advocacy.
Results:
Ninety two articles over the sample time period included discussion of medication errors. In comparison, 190 separate
articles discussing surgical errors were published in one newspaper over the same period. The main groups of news
actors quoted within articles discussing medication errors included government representatives (n=44), professional
advocacy groups (n=27), and researchers (n=18). A shortage of hospital resources was identified as the central cause of
medication errors (n=38), with efficient error reporting systems most frequently identified as a likely solution (n=25).
Government reports were cited on 39 occasions, with peer-reviewed publications infrequently cited (n=4).
The literature review uncovered three main factors associated with effective media advocacy. The first of these involves
the development of a coherent frame of reference to encourage particular views of problems and solutions amongst the
community and policymakers. Key framing techniques include: personalisation of problems through case studies of
victims; identification of the economic impacts of problems; use of metaphors to describe problems and solutions;
identification of community support for solutions; use of research to discredit non-evidence-based solutions; and use of
efficient and catchy sound-bites.
The second factor concerns the creation of diverse advocacy coalitions, as these can encourage greater community
support for policy action by allowing groups and individuals to pool resources, expertise and status. The third factor
suggests the cultivation of trusting relationships with journalists. This assists media advocacy by providing an informal
channel through which journalists and advocates can exchange information concerning research evidence and the
broader commercial and political pressures influencing editorial decisions. Such relationships aid the development of
more considered media advocacy strategies that account for the wider context in which health policy debates occur.
Conclusions:
As with other fields of health, news coverage is a key influence on quality and safety policies and practices. Yet as was
identified in this study, existing coverage is relatively limited and only marginally related to research evidence. This
suggests the need for quality and safety professionals and researchers in quality and safety to engage more strongly and
effectively with the media, as this may increase productive public discourse and gain support for evidence-based
intervention strategies.
0100
Blame and Accountability
1
1, 2
1
Nick O'Connor , Beth Kotze , Murray Wright
1
University of Sydney, Sydney, NSW, Australia
2
University of NSW, Sydney, NSW, Australia
Objectives
To discuss the role and dynamics of blame in the context of medical adverse events and to define and describe
accountability as a key component of clinical governance.
Methods
This interactive workshop presents an overview of blame in the setting of health services. Illustrative case vignettes are
used to explore issues and develop understanding of the psychological, and social dynamics at play. ‘Blame pathologies’
are described. The literature is succinctly summarised, case scenarios explored, and the authors’ ideas tested among
peer clinicians and managers. The authors have explored the phenomenon of blame in response to critical incidents in
health services. A structured discourse on three important notions of accountability is applied to the hypothetical vignettes.
Some suggestions for managing blame pathologies and for implementing a constructive culture of accountability are
presented.
Conclusions
An understanding of the phenomenology and meaning of blame is important for all clinician leaders. There are
management approaches that can identify and contain blame pathologies. Particular notions of accountability may
strengthen clinical governance.
0101
Study on the Effect of Two Educational Intervention Program on Performance of Nurses' Conveyance of
Gastroscopy-Related Knowledge to Patients
Shu-Hua Kao, Li-Ling Hsu, Suh-Ing Hsieh, Tzu-Hsin Huang
1
2
Chang Gung Medical Foundation Chang Gung memorial hospital at Taoyuan, Taoyuan, Taiwan, National Taipei
University of Nursing and Health Sciences, Taipei, Taiwan
Background: Gastroscopy is a common source of anxiety for many patients, who often refuse the test out of fear or fail to
follow the instructions of medical staffs properly, thereby making the test unsuccessful. By informing patients of the nature
and procedure of the test, nurses can make patients less nervy and more ready for the test.
Objectives: The primary aim of this study was to measure the effect of an educational intervention program targeted at
professional nurses in order to improve their ability to convey gastroscopy-related knowledge to patients.
Methods: Using a quasi-experimental, nonequivalent pretest-posttest groups design, this study involved purposive
sampling which yielded a final sample size of 65 professional nurses working at two regional hospitals and one research
hospital in northern and southern Taiwan. ata were collected using a test paper on performance of the nurses in
conveying gastroscopy-related knowledge to patients, and were analyzed using SPSS 15.0 Windows software. Repeated
measures ANOVA was conducted to measure the effect of the educational intervention program.
Findings: All nurses in the sample demonstrated enhanced performance in conveying gastroscopy-related knowledge to
patients following the educational intervention program, showing significant differences in within-group scores (p < 0.05)
between the pretest and the second-time posttest. In addition, the second-time posttest score is significantly higher than
the pretest score (p <0.001). The same within-group differences were found in both the control group and the
experimental group. No significant differences in the scores in all three tests (pretest, first-time posttest, second-time
posttest) were observed between the experimental group and the control group. However, upon meta analysis, it was
revealed that the experimental group achieved significantly higher scores in the second-time posttest than the control
group (p < 0.05).
Conclusions: It is recommended that multimedia teaching CD-ROMs and hardcopy materials be developed to educate
nurses on gastroscopy -related knowledge and to enhance ability of nurses to convey Gastroscopy-related knowledge to
patients.
Key Words: gastroscopy, educational intervention program, multimedia teaching CD-ROM, learning performance, nurses
0102
Engaging Patients with Diabetes to Improve Diabetes Care Measures using LEAN Methodology and
Individualized Patient Reports
Deanna Willis, Margaret Martin, Suzanne Engle, Rachel Riggs
1
2
Indiana University School of Medicine, Indianapolis, IN, USA, Indiana University Medical Group-Primary Care,
Indianapolis, IN, USA
Objective: To increase the rate at which patients with diabetes meet care guideline goals for blood pressure, lipids,
haemoglobin A1c, nephropathy, and foot examination care by using quality improvement methodology, including LEAN
process improvement techniques and individualized patient reports to engage patients.
Method: Initial project success was assessed using the Institute for Healthcare Improvement (IHI) Project Assessment
Score and the DICE Project Score. Voice of the Customer Analysis demonstrated a perception among providers and staff
at the clinic, that patients with Diabetes were not taking their medications regularly, causing problems in blood pressure,
sugar, and cholesterol control problems. A patient survey was performed to validate or refute this perceptions. A
diabetes registry was used to track cardiovascular risk factor control over time for patients at the clinic. Using rapid cycle
improvement methodology, a variety of strategies were implemented, including patient specific adherence reporting, use
of home blood pressure monitoring, use of blood pressure tracking cards, and individualized patient specific education
mailings showing patient Framingham cardiovascular risk score.
Results: A knowledge gap existed in patients, with 70% of patients surveyed reporting lack of knowledge of their goal
blood pressure. 55% of patients reported they did not have a way to check their blood pressure at home. 40 % of
patients reporting not being afford their medications, with an average of 3.5 days of missed medications per month due to
cost. Systolic blood pressure adherence improved from around 40% to over 66% during the 1 year period, and diastolic
blood pressure adherence increased from around 25% to over 43%. Qualitative analysis of the impact of Framingham
risk score was performed.
Conclusion: Engaging patients in improvement of diabetes care can result in significant system improvement. Standard
quality improvement methodology can be used effectively as the framework for this work.
0103
A document management system that clinician staff actually use and like
Jo Bourke, Charlie Corke
Barwon Health, Geelong, Victoria, Australia
Objective
1
To evaluate whether implementation of an electronic protocol management system (PROMPT ), a quality improvement
initiative to increase utilization of clinical policies, procedures and guidelines was effective.
Method
A pre and post observational study was conducted comprising a user based questionnaire and document utilization
indicators. Baseline utilization indicators were collected in October 2007 and then yearly for three years post
implementation. A user staff survey was conducted three years after implementation. A number of pre requisite
organisational activities were undertaken prior to the implementation of PROMPT to facilitate change management and
adoption of the system by users. Information governance requirements were established, document templates and
standards determined. The number and quality of information held in existing paper, shared drives and other data stores
were identified. Following an executive directive all documents were published on PROMPT and legacy systems were
then discontinued. Over a three year period, documents were progressively reviewed for currency, relevance,
appropriateness and duplication. They were also revised to comply with approved template standards.
The system architecture with both local and central servers ensured system reliability, compliance with disaster recovery
standards and the infrastructure to share information across and between health services.
Results
Utilization of clinical policies, procedures and guidelines increased over the three year period. Increasing from 4,455 per
month in October 2008 to 13,412 per month in October 2010. Overall the majority of users reported that PROMPT was
significantly superior to previous ‘siloed’, ad hoc management of clinical documents. The number of information
repositories decreased from five (EDMS, intranet, personal PCs, paper) to one (PROMPT). The number of documents
accessible to all staff increased by 71% (n = 810 to n = 2006). Four hundred and forty four paper based procedure
manuals were removed and condensed to 90 online documents. Currency of documents (reviewed within last three
years) increased from 12% to 97%. Rationalisation of duplicated documents reduced the total number of active
documents by 824. Sixty percent of survey respondents (n = 283) were clinicians. In 2010, seventy four percent of staff
reported that they use PROMPT and 92% indicated that they find the document they searched for. The main search
method used was by key word (82%), followed by department search (13%) and document type (5%).
Conclusion
PROMPT is well accepted, easy to use and regularly accessed. Implementation resulted in a substantial increase in the
usage of clinical policies, procedures and guidelines. Ongoing education for the minority of staff who are not current
users may be addressed by specific education to make their searching more effective. Alignment between the business
needs, the people, the processes and the technology was critical to achieving everyday use by clinicians and to ensure
consistency of information that supports the delivery of clinical practice. The development of the system by active health
care professionals was important for the success of this system. PROMPT provides additional advantages for
administrators including detailed reporting and access to guidelines in use in other institutions that were not reviewed in
this study.
1.www.prompt.org.au
0105
A “Virtual Toolbox” to Review Adverse Events in Critical Care Patients
James Robblee, Mark Cleland
University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Objectives: 1) To review two near misses related to failure of critical life support devices.
2) To use the information from the review to recommend process changes to improve patient safety.
Methods: A web-based “virtual toolbox” was used to interrogate two near misses that occurred in patients on critical life
support equipment. A web-based system has been constructed on the hospital-based clinical applications system that
allows remote real-time monitoring. The system also enables clinicians to review events, alarms and trends for the most
recent 96 hour period of the patient admission. All monitored patients and those on telemetry are included in the system.
Two recent “near misses” illustrate the utility of the system to capture events and to use critical event reviews to enable
system improvements in patient safety.
In the first case, an intra-aortic balloon pump (IABP) failed for a 39 minute period and the audible alarm failed to alert the
bedside nurse to the event. An IABP is used to support the circulation of patients with low cardiac output syndromes and
cardiogenic shock.
In the second case, an external pacemaker failed in a heart transplant patient with complete heart block. The patient was
asystolic for 80 seconds before a new pacemaker was put in place.
Results: Review of the IABP failure showed that the device functioned as expected. The software for the device includes
user preferences that default to the last user after a period of standby. A period of standby may be used to interrogate
wave forms or to assess readiness for weaning from the device. In this case, the primary nurse had disabled the alarm
while attending to the patient immediately prior to the change in shift. Following shift change, the IABP was placed on
standby. The nurse was distracted by a telephone call from the family and did not reinitiate the IABP. The error was
discovered 39 minutes later when the vital signs deteriorated.
Review of the pacemaker failure showed that a Biomedical Engineering tag had been affixed to the pacemaker indicating
that the device “shut itself off”. The device had not been removed from service pending maintenance. Biomedical review
demonstrated that the 9 volt alkaline battery was depleted. It was shown that the effective safe life of pacemaker batteries
is 14 days and that an LED warning is present 48 hours prior to failure. There is no audible alarm on pacemakers.
Conclusions: The authors conclude that the “virtual toolbox” is a useful way to analyze adverse patient events.
The project achieved the goal of identifying critical incidents that require detailed review. As a result of the review of the
IABP incident, a field has been added to the handover checklist that reminds nurses to check user preferences on all
IABP patients when covering for breaks or assuming shift duty. The manufacturer has been notified of the event and
asked to change the default setting to include an audible alarm. As a result of the pacemaker event, a battery
replacement protocol has been developed. Also, staff receive training on the actions to be followed when a pacemaker or
other powered device fails. With respect to the virtual toolbox, alarms and trends are being reviewed on a daily basis.
The authors are of the opinion that the use of the virtual toolbox improves patient safety because the reviews identify
system issues that can benefit all patients.
0108
PHSA Near Miss Project: Paying Attention to Near Miss Patient Safety Events Prevents Actual Harm to Patients
Sue Fuller Blamey, Trish Hunt
Provincial Health Services Authority, Vancouver, BC, Canada
Objective:
This project demonstrates the key results and learning derived from the analysis of Near Miss data and the strategies
used to reduce or eradicate reoccurrence of the same type of event to achieve system improvements that mitigate risk of
harm to patients.
Methods:
A retrospective analysis of cleaned near miss patient safety events for calendar year 2009 was conducted. From the 949
near miss events, high risk, problem-prone and high volume trends were identified. Based on data trends, nine process
improvement projects were developed and implemented as follows: identification of cancer patients with mental health
concerns, prevention of unprocessed physician's orders leading to missed chemotherapy, patient identification, increase
near miss and all patient safety event reporting, medication documentation and verbal orders, laboratory reports,
medication administration process, safe abbreviations, and medication reconciliation. Root Cause Analysis (RCA), Failure
Mode Effects Analysis (FMEA), and Lean were tools and methodologies used to identify systems issues and determine
possible solutions. Education and audit were incorporated into each of the quality initiatives.
Results:
Post-implementation data for the projects demonstrated improvement in the ability to reduce or erradicate the same type
of patient safety events. Using 2009 data as a base line, all projects show a reduction or eradication of the same time of
patient safety events and near misses.
Preliminary results from the Identification of Cancer Patients with Mental Health Concerns project showed a reduction
from 12 actual and near miss events to 1 near miss event. 43 critical, non-critical and near miss events were identified in
2009 prior to the Prevention of Unprocessed physician’s orders project. Post-implementation, only 1 near miss event was
identified after a 7 month period. The defect rate of unacceptable physician’s order also decreased from 70 – 3%.
Results from the Patient Identification project show a reduction of patient safety events from 88 (1 year eriod) to 31 (6
month period). The Medication Documentation and Verbal Orders project showed a reduction in patient safety events
from 136 to 77 and near misses from 33 to 8.
Results from the Medication Administration Process project showed a 20% reduction in near miss medication events and
a 7% reduction in actual medication events. There has been a marked reduction in the number of medication events
reported as originating at the medication administration stage of the medication process (38% at one agency and 21% at
another).
Results from the Safe Abbreviations project showed a reduction of 20% reduction in near miss medication events and a
7% reduction in actual medication events. There was also a reduction in the number of higher severity medication events
at both Forensics and Riverview sites. Finally, the Medication Reconciliation in In-patient Child and Adolescent Mental
Health project showed a 90% compliance at admission and revealed 38 unintentional discrepencies that were identified
and corrected through the medication reconciliation process.
Conclusions: Paying attention to near miss events that do not reach the patient and creating solutions to prevent the
same type of event from reoccurrence leads to mistake-proofing the process and an overall reduction or eradication of
actual patient safety events. As staff increases the reporting of near miss events and leaders pay attention to the
prevention of these events, the number of actual patient safety events and patient harm reduces.
0109
STAR - Sharing Techniques And Responsibilities – A Collaborated Approach to integrate Primary and Tertiary
Care in Dysphagia Management
Christina Chan, Joshua Mak
Hong Kong Hospital Authority, Hong Kong
Objective:
Swallowing disorder (dyphagia) has persistently been a hefty workload to the in-patient service of Speech Therapy in the
Hospital Authority. Associated unplanned clinical readmission and in particular, aspiration pneumonia, constitutes a
hospital utilization rate of 12% in 2008 at Pok Oi Hospital (POH). A root-cause analysis of the problems suggests causes
including late referrals, lack of tailor-made swallowing guideline and service gap for carryover to community.
Methods:
With the support of the HCE, Medical and Nursing teams of the Medical and Geriatrics Department, POH, a multidisciplinary collaboration pathway from hospital to community levels -STAR pathway-was established at:
1. Hospital level by establishing a fast-track identification and referral of dysphagic patients on day zero upon admission;
investigating their feeding history and developing swallowing guidelines covering ranges of patient-specific oral feeding
repertoire, including diet, fluid and medication swallow
2. Pre-discharge level by enhancing carryover of swallowing management via Community Liaison Nurse
3. Post-discharge level by Structured Speech Therapy Follow ups of high risk aspirators at Out-patient Clinic via
feeding-swallowing program to transfer appropriate feeding management strategies to community caregivers.
Results:
Two groups of each 80 dysphagic patients referred to the in-patient speech therapy service of POH and Tuen Mun
Hospital (TMH) during March 2009 and March 2010 were recruited. They all had at least 2 clinical admissions related to
dyshagia in 6 months’ time before the recruitment. One group, the STAR group, followed the clinical pathway in STAR
program. Another group, the non-STAR group, was managed with traditional clinical routine. Basic demographic and
medical conditions were comparable between the STAR and non-STAR groups in terms of:
1. number of dysphagia-related diseases (1.75 vs. 1.80, p = 0.610 > 0.05)
2. pre-morbid swallowing function score (5.85 vs. 6.02, p = 0.051 > 0.05)
3. admission frequency related to dysphagia pre-program (2.70 vs. 2.81, p = 0.052 > 0.05)
Statistically, there were significant differences between STAR and non-STAR groups on:
1. unplanned admission frequency related to dysphagia post-program – (0.54 vs. 2.65, p = 0.000 < 0.05)
2. within-subject reduction of unplanned admission frequency related to dysphagia – (2.12 vs. 0.22, p = 0.000 < 0.05)
3. association between the presence of STAR pathway and unplanned admission frequency was moderately strong with
2
2
eta = 0.71 (c.f. ~ 1), while that for non-STAR group, the relationship was relatively weak, eta = 0.026
Further qualitative analysis, as shown in the figure below, also revealed a better quality outcome of the STAR group
STAR Group
Non-STAR Group
Unplanned readmission related to dysphagia in 28 days
8.1%
27.5%
Sustained survival in community for more than 85 days without readmission
31.1%
2.5%
Sustained oral feeding 6 months post program
91%
55%
Deaths associated with dysphagia in subsequent readmission in 28 days
7.5%
61%
Conclusions:
Sharing the momentum of continuous improvement and sustainable healthcare exercises, the STAR program synergizes
early dysphagia identification and management across primary and tertiary settings. Not only has the avoidable
admission been reduced, the most important value of STAR is to enhance patients’ swallowing quality and safety,
bringing to the foreground concept of extended care in dysphagia management in future speech therapy.
0111
Are Spanish patients ready to overcome paternalism in clinical practice?
1
2
1
1
José Joaquín Mira , Susana Lorenzo , Merce Gulabert , Virtudes Pérez-Jover
1
2
University Miuel Hernández, Elche, Spain, Hospital Uiversitario Fundación Alcorcón, Madrid, Spain
Objective: To analyze whether patients are ready to be involved in clinical decisions and to assess whether the
information provided to them by physicians favours an active patients´ role.
Methods: A cross-sectional analysis of data on 1070 patients discharged from 7 hospitals in Spain. The data were
collected using a validated telephone survey. Study period: May and July 2009. Measurements: the patients’ role during
consultations, satisfaction with the information received, feeling of being listened to, being informed of therapeutic
alternatives, and accessibility of the doctor to deal with doubts and worries.
Results: A total of 82% (95% CI 81-85) referred to be satisfied with the information, of which 3% did not have the feeling
that their hospital doctor had listened carefully, 27% did not have their doubts cleared up, and 76% were not informed on
therapeutic alternatives. When the doctor showed a receptive attitude there was actually an increase in the number of
patients that still had doubts about their diagnosis and treatment (OR = 1.9, p-Value= 0.04). Older patients were less
frequently involved in clinical decisions (χ2 = 8.05, p-Value=0.04), and often remained with unsolved doubts (χ2=9.05, pValue=0.03).
Conclusions: Although there is an agreement on the need to overcome the paternalism in clinical practice, there are
barriers to achieve it. A substantial proportion of patients, more than initially expected, appear to assume a passive role
in the interaction with the doctor. There are conditions that may restrict the patient’s autonomy which nevertheless do not
ever affect the patient’s rating of the information provided by the doctor. These results should not be extrapolated to other
countries or to settings outside of the Spanish public health system, given the context in which the study was carried out.
0112
Promoting Quality Culture – Cross-departmental Learning Quantitative Survey
Eva LIU, Tina Ng
Queen Elizabeth Hospital, Hong Kong, China
Objective: To measure the effectiveness of cross-departmental learning that aiming to promote learning and quality work
culture as well as enhancing collegiality and communication across departments.
Methods: 30 cross-ward visits in a regional hospital of Hong Kong were conducted between January and September
2010 and a follow-up survey was carried out from December to February 2011. A structured questionnaire was used to
evaluate staff’s rating of ward improvement and knowledge gained in ten different areas including ward environment,
facilities, communication with patients, communication among staff, ward management, workflow, nursing care, safety,
privacy and staff development. Moreover, the respondents were requested to report improvements made or would be
made in their wards after the cross-departmental visits. Regression analyses were performed to test the effect of the
number of departmental visits the staff had hosted or made on having high ratings of ward improvement and knowledge
gained, adjusted by demographic data such as age, sex and staff rank.
Results: The preliminary data (ninety-eight respondents) were included in the analysis. Over 50% of respondents
assured of ward improvement made after the cross-departmental visits and more than 60% of respondents agreed that
they had acquired more knowledge during the cross-departmental visits in several areas, especially in “communication
among staff”, “ward management” and “ward environment”. General linear model analysis showed overall score of ward
improvement had significant positive association with the number of cross-departmental visits the staff had hosted (coeff.
= 0.15, p = 0.003) and overall score of knowledge gained during the cross-departmental visits (coeff = 0.42, p = 0.000).
Also, staff who had participated in greater number of cross-departmental visits demonstrated better overall score of
knowledge gained (coeff. = 0.13, p = 0.043). Majority of the respondents (91.8%) reported improvements which had
already made or would be made in their wards after the cross-departmental visits.
Conclusions: This study shows that a high degree of collegiality was demonstrated during the cross-departmental visits.
The aims of the visits to enhance ward improvement and knowledge gained, as well as improved communication and
relationships among departments have been achieved.
It has been acknowledged that many clinical situations encountered by front line managers involve misunderstanding that
leading to frustration and conflict. The essence of conflict resolution lie shared and compatible interest, as well as
collegiality. In the case of health care, quality patient care is the thrust of the business. Results of the finding suggested
that cross-departmental visits can enhance quality work and learning culture so as to provide efficient and quality health
services.
0113
Psychiatric Service Enhancement: REHAB LAUNDRY
TSANG HO-WING, LEE SHIU-CHUNG, NG SAU-YEE, LUI SIN-YI
PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL, HONG KONG, China
Background
Wearing hospital pyjamas could enforce sense of institutionalization to psychiatric inpatients. In modern Western
countries, there are growing concern and practice to strengthen self-determination and self-sufficiency by supporting
inpatients wearing private clothing during hospitalization.
Program
A REHAB LAUNDRY program had been piloted from 3Q2010 to 1Q2011 in a male psychiatric ward.
Objectives

To promote skills, habit and initiatives of personal care after the training;

To strengthen self-determination and self-sufficiency by enforcing personal autonomy over wearing private clothing.
Design and Method
A core working group was set up to develop a REHAB LAUNDRY program. It piloted from 3Q10 ~ 1Q11 to targets who
had enrolled halfway house placement. The subjects were assessed with a set of survey before commencement and
repeated over trial period. The data were analysed with opinions collation from the involved patients’ relatives and ward
staffs were solicited. The operational consumptions and difficulty would be monitored in order.
Results and Analysis
There were total 31 subjects over trial period. Thirty one subjects had completed the training and twenty seven completed
assessment. The findings suggested most participants (80%) increased in self care ability and well-being (p>0.5). They
claimed the increased self-care ability boosted confidence of recovery. Appreciations from involved patients’ relatives
were received. Limitations of the program were received, e.g. prohibited wearing belt for unfitted trousers. Comments
from ward staffs revealed regular patient-staff meeting, timely unambiguous supervision, and persistent senior
acknowledgement were critical.
Conclusion and Recommendation
This exploratory program showed that psychiatric patients appreciated wearing private clothing during hospitalization
which helped minimise sick role and enhance self esteem. The skills, habit and initiatives of personal care were enhanced
obviously among all subjects. The developed esteem was fruitful to sustainable recovery. It shed the light of clinical
services to better meet individuals’ needs. Extensive trial was recommended to different psychiatric clients and health
institutions in Hong Kong.
0114
Structured emergency preparedness enhancement
TSANG HO-WING, WONG CHI-KAN, NG SAU-YEE, TUNG CHI-WAI
PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL, HONG KONG, China
Background
Clinical emergency is rare but fatal. Effective risk prevention and quality service hinges on adequate preparedness to
wide spectrum of clinical risks and emergency. This report reviewed the outcomes of how to sustain an uplifted
emergency life-support training by a group of ward staff.
Program
It is an enforcement program to emergency life-support preparedness in a male psychiatric ward
Objectives
1.
To enable clinical nursing staff to manage wide spectrum of clinical emergency
2.
To uplift the readiness and standard of clinical emergency response
3.
To serve as platform for structured sharing of expertise and updates
Design & Method
Ward manager set up an emergency life-support training group which composed of APN and senior nurses. Some of
them had evident life-saving experiences and ACLS-provider qualification. The working group put priority efforts on the
identified top 10 clinical risks and developed a training kit integrating all relevant checklist, evaluation forms, policies and
guideline, manual and drill schedule. Members would conduct (1) regular stock-take, audit, checking of life-saving
resources, (2) prepare individual training record for ward staff, and (3) conduct regular emergency drills to assure
adequate competency. All rank of ward staffs were expected to attend at least one drill annually. All participating nurses
were required to complete a self-administered assessment before and after each workshop.
Results
There were total 16 nursing staffs completed the program over intervention period. The overall knowledge of emergency
management was persistently adequate. Vulnerable areas worthy of repeat coaching were also identified as reflected by
pre-&-post assessment (P>0.05). Continuous improvement was identified in respect of consumables and logistics at time
of emergency.
Conclusion
Nursing staff, being key players over clinical emergency, their competency was critical to control the incurred risk and
maximize effective quality service. Regular ward-based workshop and updates is paramount important to effectively
resolve problems deriving from (1) staff movement, (2) memory fade out and (3) admission of high risk group.
Recommendation
Back to basic, protection of lives and promote quality and risk-free therapeutic environment is always our top priority. Ongoing team efforts are able to sustain quality measures and sharpen alertness. Be concise, followings are pillars to
sustain uplifted emergency life-support preparedness:
1.
Regular structured training;
2.
Timely update;
3.
Appoint culture driver(s) for building of quality & safety culture; and
4.
Senior acknowledgements.
0116
HIV RELATED KNOWLADGE, ATITUDE, PRACTICE AND STIGMAAMONG DENTISTS IN GEORGIA
1
1
1
2
May-Chin Yong , Thomas Chee , Hwei-Yee Tai , Wai-Fung Chong
1
2
Tan Tock Seng Hospital, Singapore, National Healthcare Group, Singapore
Introduction:
Health care workers are often sources of HIV Stigma and Discrimination worldwide. HIV stigma still remains a serious
concern for Georgia also. The Social stigma of the infection and fear of being infected discourage Health care workers
from treating HIV infected patients. There is a documented need for dental care among PLWHA in Georgia; however
some health care workers refuse to assist HIV-infected individuals.
This is the first study regarding HIV/AIDS associated stigma and its influencing factors among health care workers in
Georgia. The findings of this important research will act as a benchmark for all further researches into the experiences of
HIV-related stigma and discrimination in Georgia.
Subjects and Methods:
Aim of our survey was to assess dentists’ knowledge on HIV infection and related practice, as well as to underline the
need for additional information/education on HIV and other blood-borne infections.
A survey was carried out in four main cities of Georgia: Tbilisi, Kutaisi, Batumi & Zugdidi. The data were collected through
administration of an anonymous questionnaire. In total 315 health care workers were interviewed. They were aged 28-57
years, with the average of 32 years.
The questionnaire was consisted of 26 questions and divided into four groups, as following: general knowledge of HIV,
protection and infection control, risks while treating HIV infected patients, and willingness to treat HIV infected patients.
The questionnaire was pilot-tested among 15 dentists at one of Tbilisi’s private clinics. Responses from the pilot-tests
were analyzed to assess the clearness and relevance of the questions, and modifications were made based on feedback
from pilot-test participants.
Results:
Results of this survey demonstrate informational gaps in dentists’ knowledge of HIV infection and emphasize the need for
additional training on HIV/AIDS infection. Only 74 % of surveyed dentists knew about HIV pathogenesis, epidemiology
and routs of the disease transmission.
Knowledge of oral HIV manifestations shows significant informational gaps. Only 43% knew all the oral manifestations of
AIDS. They were aware that hairy leucoplakia is a whitish lesion localized on the lateral parts of the tongue caused by
Epstein-Barr virus, and an almost pathognomic sign of HIV infection. 29 % of all surveyed dentists reported use of
protective masks, 32% used gloves and 12% eyewear. More than 59 % of participants have overestimated risks of
treating HIV infected patients even they are obliged to treat HIV infected patients.
The importance of delivering new information on HIV is underlined by the fact that dentists are among the first who are in
a position to see early signs of HIV infection, which include unexplained appearance of oral candidiasis, hairy leukoplakia,
herpes simplex, Kaposi sarcoma, and other symptoms of HIV manifestations.
CONCLUSIONS:
Lack of knowledge and stigma is a key barrier for the delivery of care to patients living with HIV/AIDS (PLWHA). These
findings indicated a need for urgent educational and training initiatives of HIV and AIDS for Dentists and all categories of
health care workers who have Aids associated professional risk. They are Gynecologist, surgeons and their nurses.
RECOMMENDATION:
There is an urgent need to update infection control recommendations designed to reduce the risk of transition of blood
borne diseases among health care workers. It is recommended to provide comprehensive training and retraining of health
care providers (including communication skills) to promote dissemination of accurate information on HIV/AIDS, stigma
reduction and behavior change. The training must be placed on in depth discussion on HIV/AIDS issue by experienced
health workers and lectures in order to clarify existing misconceptions and prevent discriminatory behavior.
The relevant subjects should be incorporated in both basic and continuous medical education curriculums. A relevant
code of conduct should be closely monitored by MoLHSA and NGOs working on the rights of patients. Urgent measures
should be taken to insure that health care workers, including dentists becoming aware of stigma and actively working
against it, their support and nonjudgmental care can make a huge difference in the lives of people with HIV/AIDS
0117
Cultivation and maintenance of safe ergonomic practice in patient transportation service through “Individualized
Behavioral Coaching (IBC)”
Patrick Tsz-wah So, Debbie Yuk-han Lo, Stella Wai-chee Cheng, Hin-pan So
Princess Margaret Hospital, Hong Kong, China
Background:
Hospital porters’ exposure to risks of musculoskeletal-related injuries/ disorders and safety in patient transportation had
long been a major concern in hospital settings. Individual worker’s unsafe practice (behavior) was believed to be a major
contributing factor to the situation and hence a pilot program, jointly developed by Ergonomic Consultation Team and enduser department, was conducted aiming at reinforcing the use of safe ergonomics through IBC.
Objective:
To develop, implement & evaluate the effect of a pilot program on IBC
Design:
One-way repeated measures design conducted from April to September 2010
Methods:
Approximately 50% of porters (n=30) in the central ward supporting services of an acute general hospital were recruited
into IBC program, as an additional intervention on top of a mini-lecture on safe ergonomic practice (work safe behavior)
that was delivered to all porters. Supervisors were trained to provide on-site behavioral coaching. Individual participant
attempted paper & pencil test on job-specific ergonomics knowledge before the mini-lecture and after the completion of
rd
th
the entire intervention. Real-life IBC on handling of stretcher was conducted at 3 and 13 week post-lecture by a group
of trained observer (coach). An incentive scheme was also implemented so that participants obtained 90% or above
compliance rate to safe behavior were awarded by the senior management of the work unit.
Results:
A total of 27 porters successfully completed 2 episodes of knowledge test and IBC. Their knowledge level and compliance
rate to safe ergonomic practices were analyzed with SPSS software. Paired-sample t-Test showed significant
improvement in both workers’ job-specific ergonomics knowledge (Pre-intervention mean score = 80.67%; Postrd
intervention mean score = 96%; p = 0.000) and real-life behavioral compliance (Compliance rate at 3 week = 69.23%;
th
Compliance rate at 13 week = 82.82%; p = 0.001). Participants’ feedback questionnaire indicated that more than 65% of
frontline workers held the opinions that the ergonomic intervention was useful, applicable in their daily work and enhance
safety at work.
Conclusions:
This pilot study demonstrated promising benefits in combining individualised behavioural coaching to small group jobspecific ergonomic training program. The active involvement of frontlines in identifying the risky procedures and
formulation of workable safe behaviour checklist clearly illustrated the beauty of worker’s participation and empowerment.
The future direction of which is to support the development of similar program in different workplaces and conducting
more in-depth analysis on the long term effect of this approach in healthcare sectors.
0118
Better Teamwork Climate Was Associated with Lower Catheter-Related Bloodstream Infection and Unscheduled
Return to Intensive Care Units-the Taiwan Patient Safety Culture Survey
1
3
3
3
Wui-Chiang Lee , Hwei-Ying Wung , Hsun-Hsiang Liao , Chien-Ming Lo
1
Taipei Veterans General Hospital, Taipei City, Taiwan
2
National Yang-Ming University, Taipei City, Taiwan
3
Taiwan Joint Commission on Hospital Accreditation, Taipei City, Taiwan
Objectives: to measure the teamwork climate in the intensive care units (ICUs) and to examine its association with
patient safety in Taiwanese hospitals.
Methods: the Taiwan Joint Commission on Hospital Accreditation initiated a nationwide safety climate survey using the
adapted Chinese version Safety Attitudes Questionnaire (SAQ-C). Six items of the SAQ-C define the TC dimension.
Hospitals participated to the survey on a voluntary basis between May 31 and June 30, 2008. ICU caregivers who have
worked in the ICU for at least 4 years were invited to answer the questionnaire. Using hospital as the unit of analysis, the
percentage of ICU caregivers hold positive attitudes to teamwork climate was described and compared among hospitals.
Independent factors relevant to positive attitudes were examined by univariate, multivariate, and generalized estimating
equation methods. Additionally, catheter-related bloodstream infection (CRBSI) and unscheduled ICU return rate within
24 hours were reported by hospitals. The associations between ICU’s teamwork climates and these two safety
parameters were examined.
Results: totally 7,001 valid questionnaires were returned from 123 hospitals, with the response rate 74.4% and
Cronbach’s alpha 0.748. The mean score of positive attitude to teamwork climate was 42.2. Sixty-three (51.2%) hospitals
had scores above the population mean and only 17 (13.8%) were above the international standard 60. Physician, short
working experiences (<1 year), management level, and working at medical centers were factors associated with positive
attitudes. ICUs with more caregivers holding positive attitudes to teamwork climate were less likely to have unscheduled
returns to ICUs (r=-0.719, p=0.006) and were associated with lower CRBSI rate in medical centers (r=-0.518, p=0.023).
Conclusions: The teamwork climate is not mature enough for the majorities of the ICUs in Taiwanese hospitals. Because
the teamwork is associated with patients’ clinical outcomes and safety, regular teamwork climate surveys and teamtraining programs shall be an integral part of the safety initiatives in ICUs.
0119
Relationships among Caregivers’ Burden and Quality of Life of Female Spouses of Chronic Obstructive
Pulmonary Disease Patients
Hsiu Hui Lei, Li- Ling Lin
Chi-Mei medical center, Tainan,Yung-kung, Taiwan
Objective
The purpose of this correlational study was to understand relationships among caregivers’ burden, and quality of life of
female spouses of chronic obstructive pulmonary disease (COPD) patients.
Methods
A total of 143 participants were recruited through a convenient sampling procedure from the chest out-patient department
and the COPD home care unit of a medical center from South Taiwan. The data collection period was from November,
2008 to June, 2009.The study used structured questionnaires that included four parts:the Primary Caregivers Burden
Scale, WHOQOL-BREF, and the participants’ and the COPD patients’ demographic information.
Results
Results of the study revealed:
1. The average score of caregivers’ burden was 29.34 with a highest average score of psychological domain subscale,
and a lowest average score of physical domain subscale.The average score of quality of life was 51.22. The highest
level of quality of life was the social domain, followed by the environmental and psychological domain, the lowest level
was the physical health domain.
2. The caregivers’ burden were significantly different in terms of the level of patients’ FEV1 (F=3.99, P<.05), the
frequency of admitted in hospitals (F=5.03, P<.05), and the using of oxygen (t=2.13, P<.05). However, there were no
significant differences of the caregivers’ burden on their health, economic, and educational status. The caregivers’
burden was also not related to the participants; ages and the number of year in caring of the COPD patient.
3. The levels of quality of life were significantly different in terms of the economic status (F=7.83, P<.05), educational
status (F=3.53, P<.05), and the frequency of admitted in hospitals (F=4.2, P<.05).
4. The levels of caregivers’ burden (r=-.25, P<.05) and quality of life were related significantly (r=.36, P<.05). The lower
of level of caregiver burden, and the higher of quality of life.
Conclusions
The results of this study were able to help nurses understand the COPD patients’ female spouses’ caregivers’ burden,
and quality of life. Especially for the patients with poor lung functions or the patients who were admitted hospital frequently,
the nurses should be more carefully in assessing their family conditions and the spouses’ needs in order to provide
necessary supports and assistances.
0120
Enhancement of customer satisfaction through improvement of observance rate of scheduled time and
reinforcement of guidance on waiting time
Jin Hye Park, EunSook Han, HyeYoung Choi, SeongJun Jho
Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
Objective: QA (Quality Assurance) activities were conducted to improve customer satisfaction in scheduled examination
room through improvement of items such as ‘starting the examination on scheduled time’ and ‘guidance on waiting delay
and explanation of the reason’ which received particularly low grades among evaluation items in the survey of hospital
customer satisfaction in 2009.
Design: Improvement effects of 4 measurement indicators before and after QA activities were compared by analyzing the
reasons why examination could not be conducted on scheduled time and by applying various methods for improvement of
work process in examination room and for efficient guidance on waiting time.
Participants: Targeting overall out and ward booked-patients (57,435 patients) in 11 scheduled examination rooms (EEG,
NCS, TCD, EP, Vascular, rehabilitation NCS, Eye-movement, Endoscopy, PF, Echo Cardiograph, 24hr EKG) of
department of Physiologic Diagnostic Laboratory of Seoul National University Bundang Hospital.
Main outcome measure:
- Monthly statistics of observance rate of scheduled time, customers’ observance rate of scheduled time and
examination room’s observance rate of scheduled time according to each examination room was calculated by extracting
the data on examination scheduled time, patients’ registration time and examination start time from EMR.
- Comparison the first (2010.3.1~3.19, 166 patients) with second (2010.9.6~9.27, 220 patients) customer satisfaction
questionnaire survey points for 11 evaluation items targeting out patients and ward patients.
Results: Observance rate of scheduled time of entire examination rooms increased from 74.4% before the improvement
(2010.1.1~3.31) to 79.7% after the improvement (2010.7.1~10.31), customers’ observance rate of scheduled time from
78.2% to 82.7%, examination room’s observance rate of scheduled time from 89.2% to 92.4%, and accordingly, customer
satisfaction was enhanced from 82.1 points to 91 points.
Conclusion: As the patients’ observance rate of scheduled time increased, the rate of examination room’s starting the
examination on scheduled time also increased. It was also found that customer satisfaction on hospital can be more
improved if patients’ requirements are satisfied by actively explaining the reasons of delaying and waiting time to
patients by hospital employees even if the examination starts later than scheduled time due to emergency patients.
0121
Surgical Colonoscopy – a Safe and Simple Journey
Cyrus Tse, Albert Lai, Siu-Kee Leung
Tuen Mun Hospital, Hospital Authority, NT, Hong Kong
Objective:
To review, revamp and standardize the peri-procedural events of surgical colonoscopies in a hospital cluster.
Background:
In the New Territories West Cluster (NTWC) of Hong Kong, more than 4100 colonoscopies are performed annually. This
workload is spread between the 2 parties - general surgeons and gastroenterologists, and conducted in 2 hospitals - Tuen
Mun Hospital (TMH) and Pok Oi Hospital (POH). Within each hospital, there is a separate day ward and a separate
endoscopy unit designated in handling the patients.
Method:
A 18-month project aiming at systematic review, standardization and optimization of the various factors, pathways and
protocols leading up to a surgical colonoscopy. This includes booking pathways, bowel preparations, drug regimes,
information fact sheets, international guidelines and patient education.
The key goals after the initial reviewing process is to 1) shorten idle time 2) strengthen the collaboration between different
parties and 3) ensure safe and standardized service to our patients.
In hope to achieve these goals, the following measures were implemented over this period.
1) A self-explanatory Educational Video, regarding all the various aspects of colonoscopy from indication, details of the
procedure, risks to administrative issues.
2) Defined a standardized Safety Checklist, giving recommendations and guidelines to bowel preparations, drug
regimes and admission details.
3) Collaboration with gastroenterologists, and publishing a cluster-based information Fact Sheet.
4) Completely restructure the Booking Pathways to shorten the idle time.
5) Formation of new Protocols to standardize the practice between the 2 departments and 2 hospitals.
Results:
Baseline data before the implementation of changes were gathered, and after launching of the program, a 2-week audit
was conducted in mid November 2010. In short, the following conclusions were drawn:
1) Idle Time from booking to discharge – down from 137 to 15 minutes.
2) Quality of Bowel Preparation – comparable to previous practice, with objective measures like completion rate and
polyp detection rate both up to international standard.
3) Patient Satisfaction – out of the 75% responded patients, 100% satisfaction rate.
Conclusion:
In our hospital cluster, colonoscopy represents the second-most performed endoscopy, servicing thousands of patients
each year. After reviewing and restructuring the various aspects of the procedure, we aim to deliver a simple,
standardized and safe experience to our patients.
0122
Enhancement Program to Reduce Incidents in Phlebotomy Team – Wrong Specimen Container Used for Blood
Taking
Tam May Nar, Chan Yuet Kwai, Yip Alice, Cheng Winnie
Hospital Authority, Hong Kong
Background
Incident related to wrong specimen container used is one of the top reported incidents in UCH which leads to
unnecessary delay in diagnosis and treatment such as 2 hours to 22 hours for complete blood picture (CBP) test, 15
hours to 2 days for B12/folate, because the test can not be proceed by Laboratory immediately. Consequently, patient
required to receive another attempt of invasive procedure or create patient’s complain.
Objectives
In UCH, 95 % of blood taking was performed by Centralized Phlebotomy Team. A series of program has been launched
for continuous improvement and risk reduction of blood specimen collection in phlebotomy Team since July 2009, which
aimed at controlling the no. of incident of wrong specimen container used for blood taking.
Implementation








Review the reporting mechanism by Department of Pathology.
Identify and report all wrong specimen container used incident via Advanced Incident Report System (AIRS) in
addition to LIS report by Department of Pathology.
All blood taking related incidents will be forward to Phlebotomists Service In-charge for immediate follow up.
Identify common incidents & sharing of good practices among Phlebotomy Team.
Develop Standard of Practice (SOP) of blood taking procedure.
Develop performance management mechanism for handling staff performance.
Review and re-designing the system if necessary such as poster development and upload onto Hospital Homepage.
Conduct education program by Department of Pathology and Phlebotomist Service In-charge on safe handling of
blood specimen. The contents are as below:
1. Introducing common laboratory test and use of appropriate containers.
2. Introducing incident reporting mechanism & importance of patient safety during blood taking procedure.
3. Site visit of Laboratory.
4. Demonstration & return demonstration of appropriate checking procedure during blood taking.
5. Conduct post-training assessment e.g. quiz for all attended phlebotomists.
Outcomes
In one-year observation, it was shown that the no. of incident for wrong specimen container used for blood taking is
decreasing, originally from 12 incidents in 2Q 09 decreased to zero incident in 4Q10 in Phlebotomy Team. The
awareness of phlebotomists during blood taking procedure was increased. The delay in diagnosis and treatment can be
kept to be minimal.
Conclusion
With a good initiative on enhancing quality of care to our patients, collaborative approach of Department of Pathology and
Phlebotomy Team significantly contributes to a positive outcome to patient safety culture. The incident trend on wrong
specimen container used should be observed. Refresher training and regular audit on blood taking procedure in order to
update phlebotomist knowledge and uphold their practice is necessary.
0129
Prognostic models based on administrative data alone inadequately predicted the survival outcomes for critically
ill patients at 180 days post-hospital discharge
1
2
1
1
Megan Bohensky , Vijaya Sundararajan , Sue Evans , Caroline Brand
1
2
Monash University, Melbourne, Australia, Department of Health, Melbourne, Australia,
Research Objective:
Mortality is an important and widely used outcome for benchmarking intensive care units to evaluate care and conduct
health services research. Intensive care audit has focused on patient survival until the end of the intensive care episode
or hospital discharge, but patients may be discharged alive and fare poorly afterwards.[1] In addition, different discharge
practices between units and hospitals may make comparisons of intensive care and in-hospital mortality rates inaccurate
indicators of the quality of care.[2] Consequently, examining mortality rates of intensive care patients after discharge from
hospital may be a better indicator for evaluating care and improving clinical decision-making. Risk adjustment using
acuity of illness scores, such as Acute Physiology and Chronic Health Evaluation (APACHE) scores, derived from clinical
databases is commonly performed for in-hospital mortality outcome measures. However, many clinical databases do not
routinely track patient survival after hospital discharge. Hospital administrative datasets can track long-term patient
survival but may not be able to account adequately for differences in patient risk. Using data linkage to add clinical
information to established administrative datasets can enhance the accuracy of risk models for measuring the survival
outcomes of critical care patients after hospital discharge. Therefore, the aim of this study was to compare the ability of
four methods of risk adjustment to predict and display survival of critically ill patients at 180 days after hospital discharge:
one using only variables from an administrative dataset; one using only variables from a clinical database; a model using
a full range of administrative; and clinical variables and a model using administrative variables plus APACHE 3 scores
only.
Study Design: This was a population-based cohort study. Logistic regression analyses were used to develop the models
using the entire cohort. The study sample consisted of adult (>16 years of age) residents of Victoria, Australia admitted to
one of the 12 public hospital intensive care units between 1 January 2001 and 31 December 2006. Three hospitals (1
metropolitan, 1 tertiary and 1 regional) were selected to display mortality outcomes at 180 days after hospital discharge
for patient admitted during the 2006 calendar year using standardised morality ratios and Variable Life Adjusted Display
charts.
Results: The model relying on administrative data only was the poorest predictor of mortality at 180 days after hospital
discharge (C=0.73, H-L=16.7, p=0.03). The clinical model had substantially better predictive capabilities (C=0.84, HL=8.41, p=0.39) while the full linked model achieved similar performance (C=0.85, H-L=9.34, p=0.31). Adding APACHE 3
scores to the administrative model also had good predictive capabilities (C=0.83, H-L=15.4, p=0.05). While the linked and
clinical models tended to perform similarly using SMRs and VLAD charts to display outcomes, the administrative model
displayed more exaggerated findings in all three examples leading to inaccurate conclusions about the performance of
hospitals.
Conclusions: Although the model containing administrative data only did not perform as well as the models containing
clinical variables for predicting mortality at 180 days after discharge for ICU patients, the addition of APACHE 3 scores to
administrative data substantially improved model performance to near the level of the clinical model. Using APACHE 3
scores with administrative data can reduce the burden of data capture for the intensive care registry. While establishing
data linkage systems requires some investment, linked clinical and administrative data will improve the ability to assess
case ascertainment and accurately risk adjust outcomes of patients after discharge for health services auditing and
research.
References:
1.
Angus DC, Carlet J. Surviving Intensive Care: a report from the 2002 Brussels Roundtable. Intensive Care Med
2003;29:368 - 77.
2.
Vasilevskis EE, Kuzniewicz MW, Dean ML, et al. Relationship between discharge practices and intensive care
unit in-hospital mortality performance: evidence of a discharge bias. Med Care 2009;47:803-12.
0132
Project to improve the accuracy of rehabilitation in burn patients
Chiung-Ying Tseng, Chiu-Mien Huang, Hsiao-Su Chiu, Shu-Chen Yu
Chi Mei Medical Center, Yung-kung city, Tainan county, Taiwan
Objective: This project aimed to enhance the accuracy of burn patients in rehabilitation activities and to preserve the
patient’s functional ability during hospitalization.
Methods: The multidisciplinary team was formed by surgeons, nurses and occupational therapists. The project goal was
to maximize burn patients’ functional recovery by improving the rehabilitation accuracy rate. The project began in October
2009 and concluded in December 2010. The Gantt chart was used for planning and scheduling.
Step 1: Fact and Data Finding Analysis：We analyzed data from the rehabilitation activities checklist dated October to
December 2009. The rehabilitation activities accuracy rate at discharge was 39.7% on the 14 patients with total body
surface area（TBSA）burns of 20% or greater. In addition, the physiatrists assessed the results during consultation the
mean Barthel index score（A activities of daily living assessment tool）was 56 (on a scale of 0-100), the anticipated
target score at discharge, 82; the actual score at discharge, 75. The accomplishment rate for Barthel index score was only
82%, lower than expected.
Step 2： Cause Analysis of Exception Situation: analysis of data found the possible causes identified for the poor result
include a) Lack of standard operating rehabilitation programs lead to delay rehabilitation. b) Lack of rehabilitation activities
quality control. c) Lack of education programs related to rehabilitation procedure amongst nurses d) Lacks of an
appropriate tool to assist patients perform rehabilitation correctly.
Step 3: Goal setting： In this project, we tried to improve the rehabilitation activities accuracy rate to at least 80%, and the
accomplishment rate for Barthel index score at discharge is 100%.
Step 4: Identify Outline Solution & Executive：The effect of the solutions on amelioration from April to October 2010 was
by:
a) Establishing collaboration and cooperation of mechanisms which focusing on explicit tasks, occupational therapists
applying the appropriate appliances for the individual needs, and shift to the multidisciplinary team member in order for
comprehensive care. Positioning programs should be immediately upon admission to the burn center and continue
through the multidisciplinary teamwork.
b) Establishing a rehabilitation quality-control monitoring system. The nurses must assist for technical management of
the physical treatment, and to identify changes in the patient’s condition and initiate therapeutic interventions,
continuously controlling the effect of rehabilitation activities and discussed in multidisciplinary team meeting.
c) Identifying knowledge deficits and providing education: With revised responsibilities, nurses must be educated for
implementation skill of rehabilitation to help the patients perform rehabilitation.
d) Providing supplemental educational films to replace paper guide to guide patients perform rehabilitation. Improving
the active rehabilitation accuracy in the patients via showing rehabilitation films. Additionally, applying WII games enabled
patients to early return to normal activities.
Result: The goals were achieved after implementing the changes. The accuracy rate at discharge improved to 90.5% in
the 11 subjects from November 2010 to January 2011. The inaccuracy was due to the patient habits–induced
rehabilitation position failure. The mean Barthel index score was 37; the anticipated target score at discharge, 57; the
actual score at discharge, 87; the accomplishment rate, 100%.
Conclusions： Multidisciplinary efforts are imperative for the comprehensive care of burn patient. It is also important
prior to discharge that the patient be educated continue to exercise to prevent contractures. Our hope for the future is that
by the collaboration of community and social welfare organizations and increased public awareness of the competence of
burn survivors, along the continuum of discharge planning, keep trying to improve the capacity for preserving optimal
quality of life for burn survivors.
0133
Interprofessional practice, patient safety and Junior Medical Officers: will they ever be united?
Jacqueline Milne, David Greenfield, Jeffrey Braithwaite
University of New South Wales, Sydney, Australia
Objective:
The study investigated Junior Medical Officers’ (JMOs) understanding of the connectivity between interprofessional
practice (IPP) and patient safety and explored their willingness to engage in IPP.
Methods:
A comparative case study method was employed. The JMOs in the study were in their postgraduate years of training,
from the level of intern to registrar. They were Australian medical graduates (AMGs) and International medical graduates
(IMGs) drawn from three tertiary teaching hospitals in Sydney, Australia. The two groups of doctors and three hospital
settings enabled examination and analysis across both variables. The research comprised a two phase multi-method
design. First, an extensive literature review identified four major themes for examination: culture and acculturation;
communication and interaction; collaboration and teams; and competency. Second, semi-structured interviews, lasting
between one to two hours, were conducted. Data were collated and thematic analysis was carried out with the use of
NVivo 9 data management software.
Results:
There were 30 JMOs who participated in the study. Fifteen were AMGs, over half of whom were first generation
Australians or spoke English as their second language. There were fifteen IMGs representing 11 different countries.
AMGs displayed a varied understanding of IPP, commonly linking it to working with other medical specialisations rather
than joint planning and collective expertise of all health professionals focusing on patient centred care. Most IMGs were
not familiar with the term IPP. Many IMGs came from countries whose health care systems have either limited or no
teams of allied health professionals. Almost all doctors did not fully understand the roles of non-medical health
professionals. In both groups there was little understanding about the connectivity between IPP and safety. Cultural
issues impinge on the uptake of IPP ranging from the cultural backgrounds of doctors to the culture of individual hospitals
and the cultural demographic of the patient population. IMGs from countries where the status gap between doctors and
other health professionals is large reported that the idea of IPP with non-medical professionals would not be considered.
Communication was recognised by all participants as important to patient care and acknowledged as a difficulty by most
IMGs, predominantly because of language barriers. Respect between doctors and other health professionals was
reported by nearly all JMOs as lacking, and they believe, may be partly related to stress factors. Collaborative effort was
perceived by most participants as optimal for improving safety and conceptually ideal but considered difficult to achieve in
practice. Responsibility for leadership and decision making was believed to be an issue by a number of participants who
were firmly of the opinion that the ultimate decision maker should be the doctor. Participants’ confidence in their expected
post graduate level of clinical ability was strong. Fifty percent felt their technical competencies could be improved and two
thirds reported that their level of competency had increased through working with other health professionals.
Conclusions:
IPP and its connections to safety are not well understood by JMOs, especially international graduates. A willingness to
engage in IPP is dependent on cultural factors, language skills, preparedness to collaborate and confidence in clinical
competency. Knowledge of other health professionals’ roles and mutual respect are important for engaging in IPP. These
issues highlight areas for organisations to address if JMOs are to engage in IPP and improve patient safety.
0134
New idea for Old problem: CADENZA Community Project – Health-social Partnership Transitional Care Model
(HSP- TCM) for post-discharged Elderly
1
1
2
3
Janet Wai Ying LEUNG , Kui Fu TAM , Frances Kam Yuet WONG , Siu Fun LI
1
2
3
Queen Elizabeth Hospital, Hong Kong, China, The Hong Kong Polytechnic University, Hong Kong, China, The
Salvation Army, Hong Kong & Macau Command, Hong Kong, China
Background
Aging of our population creates great demand on health care service. There is considerable pressure on doctors and
nurses to discharge patients. One of the major consequences is high rates of hospital readmission. According to the
Hospital Authority Hong Kong, the unplanned readmission rate increased from 7% to 11.1% from the Year 2000 to 2009.
Studies show that here are multiple factors (including medical and social) leading to hospital readmission. In response to
the need of the post-discharged elderly, The Salvation Army, Queen Elizabeth Hospital and The Hong Kong Polytechnic
University collaborated with 7non-governmnet organizations’ units to initiate a research study; aiming to develop a health
and social partnership transitional care (HSP-TCM) delivery model for the discharged elderly.
Study objectives
To examine the effects of HSP-TCM on: a) hospital readmission; b) perceived health outcomes (quality of life and selfefficacy); c) satisfaction with care
Study design
A randomized controlled trial with patients randomized to study or control group. Inclusive criteria: a) age 60 or above, b)
discharged home, c) lives alone, with spouse or daytime alone, d) ability to speak Cantonese, e) living within the hospital
service area, f) ability to be contacted by phone.
Patients in study group received the following interventions:
(i)
Pre-discharge phase – The nurse case manager conducted a comprehensive assessment using standardized
tools to identify the health concerns that needed to be followed up
(ii)
Post-discharged phase – 28-day Intervention Program – Nurse Case Manager (NCM) and Trained Volunteers
(TV) offered: (a) Health education (b) Home assessment (c) Medication arrangement (d) Diet management (e)
Psycho-social support

First home visit (2 – 4 days after discharge by NCM + TV)

First telephone follow up (7 – 10 days after discharge by NCM)

Second home visit (16 – 22 days after discharge by TV)

Second telephone follow up (24 – 28 days after discharge by NCM)
In addition to the structured events, the patients could initiate calls to the NCM during the intervention period to ask for
health advices and options. Nurse case manager was backed-up by Geriatrician and existing comprehensive referral
system. Patietns in the control group received usual medical care.
Results
From October 2008 to June 2010, 555 subjects were recruited (283 in control group, 272 in study group). Comparing with
the control group, the study group showed (a) 60.8% and 58.9% relative reduction in unplanned readmission rate on 28
days (4.1% vs 10.2%, p=0.005) and 84 days (7.8% vs 19.0%, p<0.001) respectively (b) improvement in patient
satisfaction (29.3 vs 40.7, p<0.001) using “The satisfaction with care instrument” (c) statistically significant improvement in
all aspects of quality of life measurement using SF36. On calculating health cost savings, 11 patients in stud group and 29
in control group had “28 days unplanned readmission”. Taking the average length of stay of 4.4 days in medical
department, and unit cost per hospital day (08/09) of HK$3650.00; the cost reduction calculated was HK$289,080.00
{$3650x4.4 days x (29 – 11)}. Similar calculation for “84 days unplanned readmission” would reveal cost reduction of
HK$529,980.00 in the study group.
Conclusion
This randomized controlled trial has proven that heath-social partnership transitional care is a cost effective model in
reducing hospital readmission, increasing elderly perceived health outcomes and their satisfaction with care.
0137
Performances of Hospitals that have undergone 4 Cycles of the Malaysian Society for Quality in Health (MSQH)
Hospital Accreditation Program
Rebecca John, M.A. Kadar Marikar
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To study the outcome of hospitals that have undergone 4 cycles of the MSQH Hospital Accreditation Program.
Methods:
A total of 6 hospitals had undergone 4 cycles of accreditation surveys from 1999 to 2010 and were measured based on
two outcomes. Firstly, Full Accreditation of 3 Years is awarded when the hospital has substantially complied with the
Accreditation standards and a 1 Year when the hospital has complied with a major number of the standards but has some
safety concerns requiring further attention. Secondly, Partial Compliance (PC) is rated when the level of compliance is 5079% while non-compliance (NC) is rated when the level of compliance is less than 50%. Lesser number of PC/NC ratings
indicates better performance.
Results:
Performance of Hospitals with 4 Cycles of Accreditation from 1999 to 2010 - Accreditation Status
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
A
B
C
D
E
F
1
1
1
1
1
1
1
1
1
1
1
0
1st cycle
2nd cycle
3rd cycle
4th cycle
Performance of Hospitals with 4 Cycles of Accreditation from 1999 to 2010 - No of services PC/NC
10
9
9
9
8
7
6
6
5
5
5
4
4
3
3
3
3
A
B
C
D
E
F
3
3
2
2
2
2
2
2
2
1
1
1
1
1
0
0
0
0
1st cycle
2nd cycle
3rd cycle
4th cycle
Of the 6 hospitals, only 1 managed to sustain 3-Year accreditation status consistently over the 4 cycles while 1 obtained
3-Year accreditation for the last 3 consecutive cycles after getting only 1-Year in the first cycle. The remaining 4 hospitals
were not consistent in their performance. The hospital awarded 3-Year accreditation continuously for the 4 cycles
performed well with no PC/NC in the 3rd cycle. Similarly, in the other hospitals when the accreditation status improved
from 1 year to 3 years, the number of PC/NC decreased. Hospitals A & F, in particular, showed marked decline in their
performance in terms of increased number of PC/NC in the 2nd & 4th cycles.
Conclusions:
Four were public hospitals experiencing frequent changes in leadership, as occurring in hospitals A, D, E & F. The impact
of high staff turnover rate resulted in poor compliance to standards. It is noted that both hospitals B and C have consistent
achievements, they were apparently private hospitals whose management and leadership were stable with low staff
turnover rate.
0139
Measuring patient safety culture in the University Hospital of Monastir (Tunisia)
Mondher Letaief, Ines Bouanene, Ines Garsi, Sana El Mhamdi
university hospital of Monastir, Monastir, Tunisia
Objective: This research aimed at assessing the culture of patient safety in a Tunisian university hospital in order to
design appropriate strategies for improvement.
Methods: A cross-sectional study, using Hospital Survey on Patient Safety Culture, was carried out in the university
hospital of Monastir (Tunisia) in May 2010. This study tool was designed to measure the 12 dimensions of the patient
safety culture. It included both positively and negatively worded items scored on a five-point likert scale.
First, the questionnaire had been translated into French to fit the Tunisian context. A pilot validity study was then
conducted to verify whether items and questions were comprehensible and clear. Internal consistency of the instrument
was measured by calculating Cronbach’s coefficient α for the 12 dimensions. Finally, the survey questionnaire was
distributed in all hospital departments to a random sample of 850 health professionals including nurses, physicians,
pharmacists and technicians.
Results: A total of 600 questionnaires were returned (response rate: 70.6%). Survey respondents were mostly employed
in medical and surgical units. Cronbach’s coefficient α value of the overall items was 0.67.
The safety culture dimensions that received the highest positive score were “Organizational learning and continuous
improvement” (65.1%) and “Teamwork within units” (61.5%). Dimension scoring the lowest was the “Non-punitive
response to error” (21.3%). “Hospital handoffs and transitions”, “Teamwork across hospital units”, “Staffing” and “Nonpunitive response to error” could be identified as weakness. Approximately, 1/3 of respondents reported that they had not
completed any event reports in the past 12 months. Only 20.6% of them gave the hospital ‘excellent’ (5.2%) or a ‘very
good’ (15.4%) patient safety grade.
Conclusion: The survey results highlighted a baseline assessment of patient safety culture at hospital level and indicated
the areas that need improvement, primarily the fear of blame. This is an important challenge to all stakeholders wishing to
address the issue of patient safety.
0140
Continuous Quality Improvement to Reduce Rates of Medication Errors in Hospitals: an absolute necessity
Mandakini Pawar, Vijay Agarwal
Pushpanjali Crosslay Hospital, Ghaziabad, UP, India
Objective: To ascertain the effect of Continuous Quality Improvement (CQI) programme utilizing innovative process of
medication administration resulting into reduction of medication errors.
Methods:
Design: Prospective Study
Setting: Pushpanjali Crosslay Hospital, Ghaziabad, UP. India
Participants:
Phase I-(Feb 2010-April 2010)-total discharges 2356
Phase II (May 2010 – Dec 2010)-total discharges 12117
Definition of Medication errors:
A medication error was defined as an error in the medication process: prescription, transcription, dispensing,
administration and monitoring. [1]
Process and Criteria:
The criteria for classifying medication errors were based upon American Society of Health System Pharmacists. [2]
In CQI, following strategies were implemented to reduce the medication errors and to improve patient safety.
1. Improved medication delivery process through information technology.
2. Medication Room was designed with bed wise medication cupboards.
3. Medication nurse (for all three shifts)
4. Systematic reporting of medication errors through Occurrence of Variance Report form.
5. Learning through medication errors.
6. Continuous training on medication safety.
7. Risk Management and Safety Committee
Results: Total discharges were 2356 during phase I and 12117 during phase II. Rates of medication errors were
successfully reduced after implementation of CQI programme utilizing innovative process of medication administration.
Medication errors per 100 discharges were 109 (4.6%) vs. 111 (0.9%) in phase I and II respectively. Types of errors per
100 discharges were further analysed, wrong dose (0.6% vs. 0.1%), wrong drug (0.7% vs. 0.2%), wrong time (3.1/% vs.
0.5%), wrong route (0.0% vs. 0.01%), wrong patient (0.0% vs. 0.0%), and wrong documentation (0.2% vs. 0.1%) in phase
I and phase II respectively. Total nursing staff was 613 during phase I and 2092 in phase II. Training compliance was 77
(12.56%) vs. 519 (24.80%) in phase I & phase II respectively.
Conclusion: Improving quality processes and patient outcomes are important issues in evolving world of healthcare.
Implementation of CQI, utilizing process and outcome surveillance plus education and performance feedback resulted in
reduction of medication errors.
References
1. Bates DW, Boyle DL, Vander Vliet MB, Scheider J, Leape L. Relationship between medication errors and adverse
drug events. J Gen Intern Med 1995; 10:199-205.
2. ASHP. ASHP Standard definition of a medication error. Am J Hosp Pharm 1982; 39:321.
0142
The relationship between social capital and internal coordination
Holger Pfaff, Tristan Gloede, Oliver Ommen, Antje Hammer
Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and
Faculty of Medicine, University of Cologne, Cologne, Germany
Research Objective: During the last decade German hospitals have been facing a changing economic and political
environment. Health care reforms have put more economic pressure on hospitals, for example, by introducing budget
constraints and reimbursement based on diagnosis-related groups. Hospitals today are forced more than ever before to
work efficiently, which requires optimal coordination among staff. The aim of our study was to analyze the impact of social
capital on internal coordination among hospital staff as perceived by the top management. We assume that higher levels
of social capital are associated with better internal coordination.
Study Design: In 2008, a cross-sectional representative study was conducted with 1224 medical directors from every
hospital in Germany with at least one internal medicine unit and one surgery unit. Among the scales included in the
standardized questionnaire were scales used to assess the medical directors’ evaluation of social capital and internal
coordination in the hospital. Both variables were measured on a six-item scale. All of the items were scored on a fourpoint Likert scale ranging from “I strongly disagree” (1) to “I strongly agree” (4). We used a multiple linear regression
model to examine the relationship between social capital and internal coordination. We controlled for hospital ownership,
teaching status, and number of beds.
Principal findings: In total we received questionnaires from 551 medical directors, resulting in a response rate of
45.2%.The first model including only the control variables hospital ownership, teaching status, and number of beds
explained nine percent of the variance in internal coordination. Including social capital in the second model led to a
change in R² of .197. The final model explained at least 28.2% of the variance in internal coordination.The positive
coefficient of social capital indicated that hospitals with higher social capital were rated higher on the scale of internal
coordination.
Conclusion: Our results indicate a significant relationship between perceived social capital and internal coordination. The
results underline the interrelationship between social capital and internal coordination. They show that internal
coordination is not just a matter of technical coordination. Investment in the social capital may facilitate better organization
of work processes in hospitals. However, our cross-sectional study does not allow us to draw causal conclusions. It could
be that social capital promotes internal coordination, but it could also be that good internal coordination fosters the social
capital of the hospital. We will have to study the nature of this relationship further using longitudinal studies.
0144
Accreditation Survey Feedback from Hospitals for 2009 and 2010
Yong Ting Poh, Saifulhazmi Salihin, M.A. Kadar Marikar
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To analyze the feedback from hospital staff in evaluating the effectiveness of the Hospital Accreditation Program with
regards to its survey process and surveyors.
Methods:
A set of questionnaire were developed and administered to hospitals which comprises of 7 questions: Q1) the length of
the survey was appropriate; Q2) the number of surveyors was appropriate; Q3) the surveyors’ approach was consultative
and encouraging; Q4) the surveyors’ comments and feedback were useful for improving our services; Q5) we felt
confident that the surveyors had a good understanding of the organization; Q6) the surveyor team had appropriate
expertise to conduct the survey; Q7) the surveyors presented as a cohesive team. 5-point Likert scale of Strongly Agree
to Strongly Disagree responses were obtained from departmental respondents of the hospitals, at the end of Hospital
Accreditation surveys conducted in years 2009 and 2010. Hospitals vary in terms of Accreditation experience from some
st
th
having gone through a 1 cycle only to several having completed the 4 cycle with either coming from the private or public
sectors. Percentages of Agree plus Strongly Agree, Neutral and Disagree plus Strongly Disagree responses were then
tabulated according to each of the 7 questions posed.
Results:
Facility Feedback on Accreditation Survey 2009 & 2010
100%
94.3%
91.0%
92.1%
90%
92.5%
93.4%
92.2%
89.3%
92.2%
90.4%
87.7%
91.0%
91.4%
89.5%
86.2%
80%
70%
60%
50%
40%
30%
20%
9.9%
10%
6.0%
3.5%
8.6%
4.6%
4.0%
5.3%
4.7%
9.6%
6.8%
7.2%
8.4%
6.4%
5.8%
0%
2009
2010
Q1
2009
2010
Q2
2009
2010
2009
Q3
Agree & Strongly Agree
2010
Q4
Neutral
2009
2010
2009
Q5
Disagree & Strongly Disagree
2010
Q6
2009
2010
Q7
Not Rated
A total of 969 respondents from 31 hospitals participated and their responses were trended by year. Only Q5 and Q6
exhibit percentage increase of Agree plus Strongly Agree responses while the others show lower percentages from 2009
to 2010. All the Questionnaire items display more than 86% of Agree plus Strongly Agree responses in both years with
miniscule percentages in the other scale of responses. The overwhelmingly Agree plus Strongly Agree feedback to the
questionnaire suggests that the hospitals as a whole regard the surveys as having appropriate duration, with the right
number of surveyors whose approaches were consultative and encouraging and who provide useful comments, with good
organizational understanding and the right expertise and also that presented themselves as a cohesive group. Conversely,
the highest Neutral response appeared in 2009 at a small 9.9% for Q5 which points to the need for surveyors to improve
on their understanding of the organization.
Conclusions:
The findings conclude that from the perspective of the clients there are no major issues with the process and satisfaction
ratio is more than 85%.
0149
Effect of Y-shape Extension Tube Development
SuJin Lee, KwangHee Park, KeungLim Choi, JinHee Lee
Seoul national university Bundang hospital, Sungnam, Keungi do, Bundang Gu, Republic of Korea
1. Objective
In clinical setting, the infusion solution set and extension tube are connected to 3-way for various purposes such as
additional infusion solution and drug injection. The existing extension is easily disconnected from 3-way, which leads to
the risk of contamination. Minivolume and T-port are used less due to their high cost. And their thin-diameter tube easily
induces regurgitation and clot formation. The delivery room of our hospital raises the drug overdose problem although
insignificant caused by the additional infusion solution and drug injection through 3-way because it pushes the remaining
drug into the extension tube. This activity is aimed to improve such problem as well as the problem of frequent
disconnection in the 3-way part in clinical setting.
2. Method
The development of the new device mentioned above was requested to a medical equipment distributor based on the
current status in using extension tube, T-port and Minivolume. The design for sample was confirmed through
brainstorming with the medical equipment distributor and applied to the clinical setting as a test trial. Throughout 6
improvements and make-up efforts, the samples with Y-port position at 3cm and 5cm to prevent the extension tube
bending phenomenon during taping were manufactured and tested. The Luer lock (locking control) was added to the end
part to prevent disconnection. The Y-shaped port developed as heparin cap was replaced with the safe cap which allows
needless injection to prevent the needle stick injury. This design is currently in progress for registration of design with the
medical equipment distributor and in review of application to our hospital integrating the opinions from s Supply Team,
General Affairs Team and QA team.
3. Result
The remaining in the extension tube was reduced from 6cc to 0.75cc (#Total capacity of the straight-type extension tube
minus Y Injected amount from Y-port of Y-shaped extension tube/Total capacity of the straight-type extension tube) x100.
The disconnection problem was improved 100% through the Luer lock(locking control) (#Number of not disconnected/
Number of Y-Shaped extension tube used) x100. Replacing Y-port with safe cap increases the safety in drug injection by
preventing needle stick injury.
4. Conclusions
Minimizing the remaining drug by applying the Y-shaped (safe port) extension tube prevented overdosed drug injection
during side injection and improved the disconnection problem between 3-way and infusion solution set. The needless
injection to the safe port also improved the safety in drug injection by removing the risk of needle stick injury.
As a suggestion is proposed to replace the PVC line made of phthalate suspected as an environmental hormone
substance with PUR (polyurethane), it seems further supplementing development is needed in the future. In addition, it is
also required to commercialize it through demanding expansion and increasing to save the higher cost than the existing
extension tube.
0151
Fighting for safety: a battle between health providers and consumers in China
1
2
1
2
Chaojie Liu , Weiwei Liu , David Legge , Yuanyuan Wang
1
2
La Trobe University, Melbourne, VIC, Australia, Peking University Third Hospital, Beijing, China
Objective: to delineate the dynamic process of interactions between patients and medical practitioners in China in
responding to patient safety.
Methods: This study was undertaken in an ambulatory care setting in Beijing, supported by the WHO Patient Safety
Small Grant. The researchers conducted indepth interviews with 22 patients, 15 health workers and 12 managers to
gather narratives regarding their perceptions and actions on patient safety. The interviewees were purposively and
conveniently selected. The interviews were recorded and then transcribed into word documents. The initial coding of the
data was developed inductively from the data. Important themes were generated through interpretation of the coding
guided by the conflict theory. Apart from testing the interpretation with the data and with the theory, further evidence was
sought through a systematic search of published Chinese literature from the Chinese Network of Knowledge Infrastructure
(CNKI).
Results: Patients had a perception that health providers made money from exploiting their sufferings. Indeed, oversupply
of medical services had been encouraged by the policies that allowed medical providers to grab a large margin of profits
from selling medicines and high-tech examinations for compensation of the low charge of labour-intensive services. Lack
of trust was a serious issue of concern. While patients took every precaution to ensure safety and quality of their own care
from the very beginning of choice of providers to the care after encounter, health workers were more concerned about
defending against potential legal consequences (if patients complaint). Both patients and physicians often attempted not
to disclose important information to the other party so that the appropriateness of the behaviour of themselves or the
inappropriateness of the behaviour of their “opponents” could be verified. Patients tended to avoid direct confrontations
with physicians through seeking second opinion, sharing information with peers, or ignoring doctors’ instructions. Nurses
sometimes became naturally a scapegoat of the hidden confrontation. A recent survey revealed that 45% consumers did
not purchase medicines according to instructions from doctors (7.4% followed advertisements; 21.1% followed advices
from commercial pharmacies; 16.4% followed self discretion); and 39％ consumers occasionally (13% never) disclosed
their medication information to doctors. Obviously, such an interaction process left large room for medical errors. Despite
great efforts in recent years made by the Ministry of Health in promoting a systems approach to patient safety, adverse
events had usually been investigated as a result of single service procedure. There was a surge in Chinese publications
about research into adverse events in 2010. The 2010 publications comprised 44% (136/310) of total publications about
adverse events. However, those publications had been dominated by reports on patient adverse reactions to medicines
(42%) and medical devices (19%), and accidents in nursing care (20%). Reports and commentaries on adverse medical
events comprised less than 11% of the total publications. Unfortunately, patient safety had not been put into priority of the
agenda of medical practice. There was a taboo to challenge the authorities of doctors in China.
Conclusions: China is confronting great challenges in patient safety. It is important to acknowledge that patient safety
depends on actions from a wide range of stakeholders. Lack of participation from medical practitioners has seriously
jeopardised the patient safety initiatives. Building trust among those stakeholders is essential for the development of a
systems approach based on non-punitive response to medical errors. Policy makers and health care managers need to
align financial and personnel incentives with the goal of patient safety. Doctors should play a critical role in preventing and
correcting errors and addressing system problems. Improving health literacy is important for consumers to be effectively
engaged in managing the safety of their own care.
0152
Enhancement of Patient identification During Drug Issuing Process to Patient in Out-patient Pharmacy and
Standardization of the Practice among NTWC Hospital Pharmacies.
Agnes TAM, Pauline CHU, Josephine Yung, Dylan Tse
Pok Oi Hospital, Hong Kong
Objective:
Ensure patient collect the right medications by using 2 identifiers which are correct patient name and correct ticket
number.
Methods:
-To avoid issue medication to wrong patient due misidentification of the patient name or ticket number and to standardize
the process among NTWC hospital pharmacies.
-After the root causes analysis that font size of current ticket number is too small both the portion with bar code ticket
number and portion to patient with ticket number. Furthermore, noisy environment always contribute the cause of patient
misidentification in out-patient pharmacy. Pharmacy has installed intercom to enhance the communication over the
counter to solve the noisy environment. By changing the ticket printer with larger number font size to improve the visual
impact for both pharmacy staff and patients during the checking process.
-A patient satisfaction survey was carried out after the use of the new type of ticket printer in Jan 2010. More than 55% of
the patients would prefer to use the new ticket printing because of much better visual effects with larger font size. 21%
with no comments and only 24% prefer to use the old type.
-In June 2010, an improvement project was implemented to all hospitals in NTWC. Staffs have to comply with 2 identifiers
before issuing drugs to the patient with standard documentation and good compliance in practice.
1. The person who collect drug must able to name the patient name correctly if unclear should check ID..etc
2. Staff has to collect ticket number from the person and affix it onto the prescription and checked against with the
bar code ticket number as compliance of checking and record for future tracing if necessary
-A chop has been designed to facilitate cases with ticket missing scenario. Very often, patient may throw away the ticket,
place it somewhere else or even ask someone to collect the medication on behalf of him without the ticket…etc. The ticket
missing chop is made to enable staff to have proper documentation and comply with 2 identifiers checking even without
ticket.
-To ensure staff could follow closely to the new improvements. Internal guidance was designed to remind staff to comply
this new guideline on patient identification in June 2010.
-Two audits were carried out to review the compliance in Aug 2010 after the implementation.
Results:
- Incident of patient misidentification is avoided after the implementation of the enhancement.
- There are 3 major hospitals in NTWC : TMH, POH and CPH
1.Audit on compliance of sticking ticket number checking
procedures are 100% in both POH & CPH, 95% in TMH
2.Audit on compliance on ticket missing handling
procedures are 100% in both POH &CPH, 80% in TMH
Conclusion:
-To maintain a safety culture that “right patient” collects “right mediations” among the cluster had been achieved.
-Plan to roll out to the rest of 6 general out-patient clinic pharmacies in 2Q 2011.
-The compliance of sticking ticket number onto the prescription is very essential as it is a good tracing tool in situation if
wrong drugs were given to patient due to mismatch with the ticket number. The wrong patient identification could be
rectified immediately.
0153
Outcome of MSQH Surveyors Training Program 1998-2008
M.A. Kadar Marikar, Rebecca John
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To analyze the outcome of surveyors selection for the surveyors training programs.
Methods:
MSQH surveyors are selected from a pool of senior health care personnel, such as Chief Executive Officers, General
Managers, Executive Directors, Clinical Directors of health care facilities, Clinical Specialists, Directors of Nursing, Chief
Nursing Officers and Senior Hospital Engineers, who have had at least 10-15 years in the provision of health care and
health care related services. They must possess professional technical and managerial expertise as well as necessary
interpersonal and communication skills to fulfill their total role as enablers, educators and evaluators. Potential candidates
undergo special training in theory and practice before they are appointed and privileged as surveyors. The training
provides them with knowledge and understanding of the principles and requirements of the Hospital Accreditation
Standards, so that they can objectively evaluate the level of compliance to MSQH standards, identify opportunities for
commendation and improvement, and make recommendation for continuous quality initiatives. After initial training, the
selected candidates are required to undergo on-site practical training as an Observer Surveyor before they are appointed
and privileged as a member of the survey team.
Results:
MSQH Surveyors' Training 1999-2008
100%
91.7% (22)
88.9% (16)
87.0% (20)
90%
80%
(12)
66.7%
70%
Percentage
(13)
60%
70.0% (28)
61.5% (16)
57.9% (22)
56.5%
54.2% (13)
53.6% (15)
(13)
50.0%
50%
(19)
50.0%
(18)
45.0%
40%
(8)
28.6%
30%
20%
10%
0%
1999
2000
2001
2003
Years
2004
2006
2008
Percentages Appointed as Surveyors
Percentages Active till to date
Only in the years 1999, 2000 and 2003, more than 80% trained were privileged as surveyors. The remaining years had
below 70% outcome.
Conclusions:
st
nd
Surveyors play a major role in carrying out the Accreditation programs to hospitals. Participants for the 1 and 2 groups
in years 1999 and 2000 respectively were very senior staffs who were involved in the development of the Accreditation
program with high level of ownership and commitment. As of to date, they had between 11 to 12 years of Accreditation
experience. While the groups from 2001 onwards, were solely based on open application and on fulfillment of established
criteria. Additional criteria must hence be identified and be subjected to aspiring surveyors to increase the likelihood of
them to remain active and continue with surveying activities. Selection of potential surveyors to participate in the training
programs must be improved to create a better and efficient process and sustain a pool of surveyors with longer
Accreditation experience.
0154
Reduction of initial response time in Acute Myocardial Infarction patients
M.J. Jang, H.C. Gwon, S.H. Choi, M.S. Sim
Samsung Medical Center, Seoul, Republic of Korea
Objective:
Acute Myocardial Infarction (AMI) could be fatal by delayed initial response time (IRT) to early AMI.
We found some problems in response to AMI patients who need prompt action. Although we reduced the
IRT after the improvement program applied in Samsung Medical Center from 2004 to 2006, it did not meet the ACC/AHA
guideline which is within 90 minutes (mins). Therefore, to reduce IRT to AMI patients, we need to analyze the problem and
develop new working process.
Methods:
We analyzed IRT to AMI patients. The sample included 52 Korean men and women who arrived in emergency room (ER)
within 12 hours after symptoms occurred from Jan. to Sep. in 2009. They were diagnosed as AMI when discharged from
hospital.
Analysis by Fish bone shows that key factors which affecting IRT were complicated report system due to multi-step
reporting, insufficient AMI management system, lack of knowledge on AMI, missing of recording assessment index items,
and facilities issues such as congested ER and shortage of ER beds.
Before application of the improvement program for IRT to AMI patients, we followed three assessment steps. In first triage,
patients with chest pain saw an ER doctor. Then, when needed, they were registered in acute chest pain center in second
triage. After that, resident called Cardiologist after ECG and blood test results came back.
After application of improvement program, when patients with chest pain arrived at the ER, we checked ECG to them, first.
If doubted ST elevation, MI team was called immediately by ER resident. It was called ‘One-call system’ which operated
according to standardization work process. Retraining was given regularly to resident doctors on critical guideline.
In addition, one-call system poster was attached at acute chest pain center room in ER, medical team was forced to carry
pocket manual on one-call system and ECG was re-trained to them. To improve patient’s management system, we
secured 4 more intensive care unit (ICU) beds, and 2 sub-ICU beds were always standing by. We also developed
electronic medical record (EMR) for chest pain record to prevent loss of patient’s important information.
Results:
Operating one-call system, training of medical team, carrying pocket manual, improvement of facilities issues and
development of EMR shortened median of IRT from 94.5(Interquantile range (IQR) 76-115)mins 2007-2008 to 75(IQR
58-84) mins during the one-call system advertizing period between Jan. and Apr. in 2009, and 61(IQR 47-83) mins during
one-call system operating period between May and Sep. in 2009. The goal of IRT, less than 90 min, was also achieved
from 45% in 2007-2008 to 96% in 2009.
Conclusions:
We say ‘Time is myocardium’, that is, AMI is fight to time. Quick response and treatment, reducing IRT, is essential to
AMI. Acute chest pain center in Samsung Medical Center developed and operated standardized one-call system working
process. We also developed EMR chest pain record, resolved facilities issues, and trained medical team. As a result, we
reduced IRT and hospitalization time. And we may improve quality of care and provide proper medical service to AMI
patients.
0156
Strategies used to improve the understanding of PICU nurses to ECMO
Ching-Yun Sun, Yi-Yu Lin, Hsiao-Ping Huang
Chang Gung Memorial Hospital; Kaohsiung-Medical Center, Kaohsiung, Taiwan
Aim
Rapid advances in medical technology allows extra - corporeal membrane oxygenation (ECMO) to provide long term
support and possibly reverse the predicted clinical deterioration for critical patients with cardiopulmonary failure. ECMO
seems to provide hope for the critical ill patients, but on the contrary, intensive nursing staff had reported increased onus
and iatrogenic related medical error related to the adequate manipulation of this sophisticated device.
Methods
32 questionnaires and interviews were assigned to 32 PICU nursing staff inquiring them about questions and basic
knowledge associated with nursing care evaluation protocol for ECMO. 32 valid questionnaires were collected. Thus we
achieved a valid questionnaire rate of 100%. Our nursing staff members scored an average of 50.33%. In order to
establish a standard nursing care evaluation protocol for ECMO,
Our results came up with the overwhelming discovery of the fact that most nursing staff were unfamiliar to ECMO due to
lack of basic medical knowledge regarding this new device, lack of clinical nursing experience with critical patients who
are using the ECMO device and lack of continuing in-service education via experienced ECMO specialists who can
provide basic understanding of ECMO. A clinical case vignette was also presented during morbidity and mortality
conference to prevent future mistake from happening. In order to improve the nursing care, we introduced various
interventions such as: 1)augmenting our nursing staff with continuing in-service education providing basic understanding
of ECMO; 2) establish a general PICU ECMO guideline with detailed photos and labels; 3) provide clinical probation
teaching in which senior nursing staff in charge of patients on ECMO who are experienced enough to share their clinical
experiences with junior nursing staff.
Results
The results of our interventional strategy showed a statistically significant improvement from 50.33% to 90.2%. Thus we
proved that designing a nursing care evaluation protocol for ECMO; establishing a general PICU ECMO guideline
together with daily recording of ECMO observation chart; continuous in-service education on ECMO; and providing clinical
probation teaching will indeed improve our nursing staff’s understanding of the ECMO and its clinical application.
Discussions
The specially designed questionnaires and interviews used to collect our data revealed poor marks from our nursing staff.
Possible reasons are lack of clinical nursing experience with critical patients who are using the ECMO device, lack of a
general PICU ECMO guideline together with daily recording of ECMO observation chart and lack of continuing in-service
education via experienced ECMO specialists who can provide basic understanding of ECMO. Interventional strategies
such as general PICU ECMO guideline was established and promoted. Continuing in-service education via experienced
ECMO specialists who can provide basic understanding of ECMO. A standardized daily recording of ECMO observation
chart should be designed for the nursing staff. The results of our interventional strategy showed a statistically significant
improvement from 50.33% to 90.2% (during our evaluation period). Thus we proved the fact that continuous in-service
education via experienced ECMO specialists who can provide basic understanding of ECMO is positively associated with
the nursing staff’s basic medical knowledge concerning ECMO; thus our ECMO group decided to enroll this course as a
compulsory course into our continuous in-service education annually. The most valuable findings from our research is the
fact that our ECMO group provided many handy tips regarding nursing care and trouble shooting strategies associated
with ECMO. Our nursing staff also reported more confidence regarding ECMO patients’ bedside care and no more
episodes related to iatrogenic complications were reported.
0159
"Noiseless OR Project" for noise reduction in Operating Room
Jebog Yoo, Kesook Yoon, Eunkyung Kim, Eunhee Na
Samsung Medical Center, Seoul, Republic of Korea
Objective:
Noise is defined as sound that is loud, unpleasant, unexpected, or undesired. There is little information on the sound
levels in an operating room (OR) environment. In OR, both patients and physicians are often exposed to a variety of
noises. Common sources of noise include anesthetic machine, ventilation system, surgical equipment, auditory alarms,
telephone, conversation, etc. Excessive noise in the OR is a major area of concern that may increase anxiety and stress
levels, decrease patient satisfaction, and increase the risk of hearing damage to patients and the medical staffs. The aim
of this study was to reduce noise in OR by incorporating noise reduction project.
Methods:
1. A preliminary survey of noise levels was performed in the OR and background noise levels (dB) were measured with
sound level meter for a 10-min interval in 25 operating rooms.
2. The sources of noise in OR were identified and recorded on video tape.
3. When noise level was high, ear plugs were provided to patients and guardians. Also, ear protector was provided to
physicians during the operation.
4. The guideline for noise reduction project for OR was developed and performed for 10 months.
Results:
1. After noise reduction project, background noise level decreased from 71.2 dB to 64.1 dB (11.1%) and average surgical
noise level decreased from 71.8 dB to 58.4 dB (18.6%).
2. After noise reduction project, staff’s satisfaction score significantly increased from 2.82 to 3.40(45%).
3. Staff’s physiological response score significantly increased from 3.19 to 3.32 (13%) and staff’s emotional response
score significantly increased from 2.87 to 3.05 (18%). These values were measure on 4-likert scale.
Conclusion:
After performing noise reduction project for 10 months, there was a meaningful decrease in background noise level in OR.
Reduced noise level in OR is important on both patients’ and medical staffs’ standpoints in which quiet environment in OR
may be helpful in alleviating anxiety and stress before and during the operation. Medical staffs acknowledged the need for
noise reduction project in OR, but persistent effort in following these guidelines is a matter of concern.
0162
Emergency Department Clinical Instability Criteria: starting patient safety systems at the hospital front door
1
2
2
Julie Considine , Elspeth Lucas , Bart Wunderlich
1
2
Deakin University - Northern Health Clinical Partnership, Burwood, Victoria, Australia, Northern Health, Epping, Victoria,
Australia
Objective: The aim of this study was to evaluate the revision of Clinical Instability Criteria in the Emergency Department
at The Northern Hospital, Victoria, Australia
Methods: The Emergency Department at The Northern Hospital manages over 61,000 adult and paediatric presentations
annually. In 2006, Clinical Instability Criteria were implemented as a proxy for an early warning system / rapid response
system. In early 2009, there was poor compliance with activation of this single trigger system and during April 2009 there
was only one activation for the month. In May 2009, the Emergency Department Clinical Instability Criteria and activation
process were revised and structured implementation consisting of inclusion in the Emergency Department orientation
program for all staff, visual prompts in each patient cubicle, and staff education was used to launch the new Clinical
Instability Criteria. The current adult Clinical Instability Criteria are: stridor / upper airway obstruction / threatened airway;
respiratory rate < 10 or >30 breaths / minute; oxygen saturation <90% (on oxygen at 10 litres/minute via mask); pulse
rate <50 or >120 beats / minute; systolic blood pressure <90 or >200 mmHg, urine output <20 mls / hour or <100 mls / 6
hours; pH <7.20 on blood gas analysis; sudden decrease in the level of consciousness (fall in Glasgow Coma Score > 2
points) or nurse concern. The paediatric Clinical Instability Criteria have similar parameters with age related values. This
single trigger system is activated if a patient meets any one of the Clinical Instability Criteria During activation, the
physiological abnormality is reported to the nurse in-charge of the shift and coordinating Emergency Physician and the
patient is be reviewed by the Emergency Physician within 5 minutes of activation. Following these changes, there were
1522 CIC activations from May 09 to December 2010: a random sample of 10% of activations per month was selected for
this audit (n = 147).
Results: The median age of patients requiring Clinical Instability Criteria activation was 65 years, 65% arrived in ED by
ambulance, 45% were triaged to ATS* category 2 (maximum waiting time = 10 minutes) and 42% triaged to ATS*
category 3 (maximum waiting time = 30 minutes). Only 14% patients went home and the remainder required hospital
admission: of these, 5 patients required intensive care unit admission and 6 patients were admitted to the coronary care
unit. Just over half (55%) of the Clinical Instability Criteria activations occurred in monitored cubicles and 27.9% occurred
in general cubicles. Nurses activated 98% of Clinical Instability Criteria calls and 62.5% of activations were made by
nurses without postgraduate qualfications in emergency nursing. The median time to Clinical Instability Criteria activation
after documentation of physiological abnormalities was 5 minutes. The most common reasons for Clinical Instability
Criteria activation were hypotension (31%), tachycardia (28%), tachypnoea (8%) and hypoxaemia (7%). The most
common interventions were intravenous fluids (40%) and supplemental oxygen (21%). Clinical instability was resolved in
72% of patients however the median duration of clinical instability was 45 minutes. Only 6% of patients required recurrent
CIC activations.
Conclusions: The assumption that Emergency Departments can manage their own patients with clinical deterioration
simply though availability of specialist medical and nursing staff is flawed. Emergency Departments have high numbers of
undiagnosed and undifferentiated patients at high risk of clinical deterioration, Further, there are many inexperienced
clinicians working in Emergency Departments and while appropriate supervision is important, there needs to be additional
patient safety systems to ensure timely recognition of clinical deterioration and management by senior clinicians.
Structured implementation of revised Emergency Department Clinical Instability Criteria has increased reporting of clinical
deterioration in Emergency Department patients, particularly by inexperienced nurses. A greater understanding of the
most common reasons for clinical deterioration in Emergency Department patients enables an objective and evidencebased approach to clinical risk management and can inform physiological surveillance, early warning systems and rapid
response systems in Emergency Departments.
* ATS = Australasian Triage Scale
0163
Performance of Malaysian Hospitals Undergoing Focus Surveys in 2007 to 2009
Yong Ting Poh, Saifulhazmi Salihin, M.A. Kadar Marikar
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To provide a descriptive analysis on the performance of hospitals that underwent focus surveys under the Malaysian
Hospital Accreditation Program conducted from 2007 to 2009.
Methods:
The MSQH awards a 3-Year Accreditation Status to hospitals that substantially comply with the MSQH Standards. One
year Accreditation Statuses are awarded to hospitals that partially comply with the Standards. However, there will be a
focus survey between the next 6th and the 12th month to address and resurvey services that have been rated as partial
or non compliance and recommendations as provided in the feedback report. During the focus survey, the hospital needs
to substantially comply in all the areas of concern as identified in the report, to obtain the additional 2 years. A non
accreditation status will be provided to hospitals that do not comply with a significant number of the standards.
Results:
Hospital undergone Focus Survey in 2007, 2008 & 2009
100%
100%
100%
92%
90%
86% 83%
78%
80%
73%
71%
Percentage
70%
60%
50%
40%
38%
34%
33%
30%
30%
17%
20%
11%
9%
10%
9%
0%
8%
10%
0%
0%
2007
2008
2009
Total
Years
Awarded one-year accreditation status
Undergone Focus Survey
Awarded additional two-year accreditation status
Non Accreditated status after Focus Survey
Non Accredited (do not undergo Focus Survey & non-accreditated after focus survey)
Conclusions:
A majority of the hospitals that were awarded a 1-year Accreditation status took the initiative to undergo the focus survey.
The figures demonstrate that these hospitals were able to rectify the problems that were brought up in the initial survey
and recommendations of the surveyors were acted upon. Such outcomes are in congruence with the objective of the
Hospital Accreditation Program which is to encourage the continuous improvement of healthcare facilities and services.
However, there were several hospitals that were not given the additional 2 years. They were either unable to obtain
accreditation after the focus survey or those that decided not to undergo the focus survey. Hospitals that did not go
through the focus surveys are mainly due to the infrastructure problems of the hospitals that could not be overcome within
a one year period while a focus survey needs to be conducted within a year of the initial accreditation survey. From years
2007 to 2009, 71% to 86% of those attaining 1-year Accreditation statuses went through focus surveys, and between 83%
to 100% of them achieved an additional 2 years of Accreditation. On average, 78% volunteered to undergo focus surveys
and 92% successfully responded to the recommendations to eventually gain full Accreditation.
0166
Measuring Outcome of Hospitals Surveyed Using the 3rd Edition of the Malaysian Hospital Accreditation
Standards from Years 2009 to 2010
Noramiza Md Nasir, M.A. Kadar Marikar
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To analyze the outcome of hospitals surveyed in years 2009 and 2010 using the 3rd Edition of the Malaysian Hospital
Accreditation Standards.
Methods:
A study of hospitals having been surveyed in 2009 and 2010 was conducted in which findings were extracted from survey
reports on hospitals that went through the Malaysian Hospital Accreditation Program using the 3rd Edition Standards. All
the hospitals went through the new Accreditation standards for the first time. Hospitals with full Accreditation status
performances are being awarded a 3-Year Accreditation. Comparisons were made particularly between specialist and
non-specialist hospitals, year and Accreditation Status.
Results:
Accreditation Status
3 Year
1 Year
No. Of Hospitals Surveyed
2009 (%)
2010 (%)
2009 (%)
2010 (%)
Specialist Hospital
12 (70.5)
15 (71)
5 (29.5)
6 (29)
Non-Specialist Hospital
4 (67)
4 (80)
2 (33)
1 (20)
Outcom es of Hospital aw arded 3 Year Status
Outcom es of Hospital Aw arded 1 Year Status
80%
80
70.5%
70
67%
80
71%
70
60
Specialist
40
Non
Specialist
30
Percentage
Percentage
60
50
50
Specialist
40
33%
30
Non
Specialist
29%
29.5%
20%
20
20
10
10
2009
2010
2009
2010
Total number of hospital being surveyed in 2009 and 2010 was 23 and 26 respectively. The percentage of hospitals being
awarded 3-Year status has increased in 2010 (73%) compared to 2009 (70%). For specialist hospitals with 3-Year Status,
from year 2009 to 2010, there is slightly increased of 0.5%. However, the percentage of hospital been awarded 3-Year
Status for non-specialist hospitals, has increased significantly from 2009 (67%) to 2010 (80%).
Conclusions:
1) The outcomes of hospitals surveyed in 2009 and 2010 showed improvement with the increased number of hospitals
awarded with 3-Year Accreditation Status.
2) Further analysis on the hospitals with 3-Year Accreditation Status showed that Non-Specialist hospitals performed
better than specialist hospitals. This maybe due to the level of complexity and the expanded services offered by the
Specialist hospitals as compared to the non-specialist hospital.
3) The percentage increase in the hospital with 3-Year Accreditation Status during the 2009 and 2010 reflects the
gradual introduction and compliance to the new Standards.
0167
Stimulating hospital accreditation: what can hospital federations do?
1
2
3
4
Johan Hellings , Johan Pauwels , Katrien Moors , Birgit De Volder
1
2
3
University Hasselt & ICURO, Diepenbeek, Belgium, Zorgnet Vlaanderen & ICURO, Brussels, Belgium, Jessa
4
ziekenhuis, Hasselt, Belgium, UZLeuven, Leuven, Belgium
Objective: Stimulating Flemish hospitals to start an accreditation process, as part of an integrated Quality and Safety (Q
& S) plan.
Context: Belgium does not impose accreditation on hospitals at present, nor does it have its own accreditation
organisation. However, a few hospitals have taken the initiative to seek accreditation by an existing accreditation body. In
2008 the Virga Jesse ziekenhuis (now Jessa ziekenhuis) was the first hospital in Belgium receiving a hospital
accreditation by the Nederlands Instituut voor Accreditatie in de Zorg (NIAZ) followed by University Hospitals Leuven in
2010 by the Joint Commission International (JCI). This two leading hospitals gave an inspiring example to other hospitals
in Flanders. In the beginning of 2010, the two Flemish hospital federations, Zorgnet Vlaanderen (private hospitals) and
ICURO (public hospitals), made an agreement to work together in a structural way and give more support to their member
hospitals in the Q & S domain. A Q & S plan (2011 – 2013) for general hospitals was developed and discussed with the
member hospitals. Key elements in this plan, which is endorsed by the Flemish Minister of Health, are developing and
integrating process and outcome indicators for internal use, moving them step by step to the use for public reporting,
together with hospital accreditation.
Initiatives:
•
Spring 2010: a brochure with a description of the accreditation process was developed and sent to all Flemish
hospitals.
•
June 1, 2010: a first accreditation seminar was organised by the hospital federations for the Flemish hospitals
focusing on the theoretical aspects of accreditation. Also both NIAZ and JCI presented their accreditation
program and approach. Delegates of 40 hospitals participated in this seminar.
•
September 30, 2010: the hospital federations started with a monthly Q & S workgroup. Delegates of 46 hospitals
participate in this workgroup. The hospital federations informed the Flemish hospitals of their initiative to start and
support a workgroup in 2011 for the hospitals embarking with an accreditation process. Next to accreditation also
other elements of the Q & S plan, such as the Flemish Hospital Indicator Project, were discussed.
•
December 17, 2010: a second accreditation seminar was organised by the hospital federations for the Flemish
hospitals. In this seminar the theme was accreditation in a European context with a focus on process and
outcome. Both international and national experiences were presented in this perspective. Delegates of 56
hospitals participated in this seminar.
•
January 26, 2011: the Flemish Hospital Indicator project was launched in cooperation with the Flemish
Association of Medical Directors and the Flemish Agencies responsible for quality and safety in hospitals.
•
February 28, 2011: the accreditation workgroup of hospitals embarking with an accreditation process was
launched with the participation of 35 Flemish hospitals.
Results:
•
The Flemish hospital federations were able to stimulate their member hospitals to start an accreditation process.
The inspiring example of leading hospitals and their willingness to share experiences is giving a major impulse.
•
32 Flemish general hospitals (43% of all Flemish hospitals) and even 3 psychiatric hospitals decided to start the
preparation of a hospital accreditation with either NIAZ or JCI. An important first step on the accreditation journey
is taken strongly supported by the hospital federations.
•
As this hospital federations initiative is strongly supported by the Flemish government, debate has started on new
perspectives for future government regulation.
0171
Comprehensive evaluation of the perceived usefulness of a set of hospital accreditation standards
Katrine Nielsen, Carsten Engel
IKAS, Aarhus, Denmark
Objective:
The purpose of this study was to perform a detailed and comprehensive evaluation of the perceived usefulness of a set of
hospital accreditation standards as a tool for quality evaluation and quality improvement.
Methods:
The standards evaluated were the hospital standards of the Danish Healthcare Quality Programme. The programme is
mandatory for public and private hospitals in Denmark.
The standard set was released in August 2009. Accreditation surveys commenced in May 2010 and will encompass all
hospitals by mid 2012.
The study presented was part of a systematic evaluation preceding the process for developing a revised version of the
standards, due to be published in 2012.
The evaluation was carried out from Jan 2011 – Mar 2011. A questionnaire was sent to all hospitals having had external
survey in 2010 (n = 17) and to all hospitals preparing for survey in 2011-2012 (n = 73). Response was sought from the
hospital management with involvement of the hospital quality committee. The same questionnaire was sent to the quality
departments of the five Danish Regions, who are the owners of the public hospitals. The questionnaire both included
multiple choice questions and spaces in which the respondents in a more qualitative way could add comments to the
standards.
Results:
The study investigates:
-
If there are standards that are perceived as particularly difficult to achieve, and why so
-
If there are standards that are perceived as superfluous, and why so
-
If there are important issues that are not addressed by the existing standards
-
For each individual standard whether this particular standard has been a useful tool for quality improvement in the
hospital, and if not, why so
Analysis of data will reveal, whether the usefulness is perceived different between public and private hospitals, between
general hospitals and psychiatric hospitals, and between hospitals having had external survey, preparing for survey in the
near future, or preparing for survey in the somewhat more distant future.
Conclusions:
In the conclusion we will summarize
-
Types of standards found useful by a majority of responders
-
Types of standards found not useful by a majority of responders
-
Patterns of reasons for standards not being found useful
-
Patterns of differences in opinions between responders
0173
A trial of short notice surveys in two accreditation programs: views of accreditation surveyors and health care
organisational staff.
1
2
2
2
Margaret Banks , David Greenfield , Johanna Westbrook , Jeffrey Braithwaite
1
2
Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia, Australian Institute
of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
Objective:
To examine accreditation surveyors’ and health care organisational staff’s views of a trial of short notice surveys (SNSs)
in two accreditation programs.
Methods:
The first trial involved 20 healthcare organisations and applied standards from the Australian Council on Health Care
Standards (ACHS) Evaluation and Quality Improvement Program (EQuIP). The second study involved seven general
practices and applied standards of the Australian General Practice Accreditation Limited (AGPAL). A questionnaire was
administered to participating surveyors and health care organisational staff to examine their experiences of SNSs, and the
impact of the SNS on the organisation, staff and patients. Analysis was undertaken in three ways: all groups of
respondents as one set; a comparison of surveyors’ and organisational staff views; and ACHS and AGPAL surveyors’
experiences were contrasted. Data were analysed using descriptive and inferential statistics.
Results:
There were 95 questionnaires returned. The ACHS trial contributed 74 responses - 23 from surveyors and 51 from health
care organisational staff. There were 21 surveys received from the AGPAL study - 14 from surveyors and 7 from health
care organisational staff. Majority agreement was reported by respondents for the following: SNS is an appropriate
method to be used in an accreditation program; SNSs support and validate an organisation's continuous quality
improvement efforts; SNSs provide an accurate picture of an organisation's day-to-day performance; and health
professionals were comfortable in participating in an SNS. Of 11 total survey items, significant differences between
surveyors and staff were found for 6 items. Surveyors were more likely than staff to agree that the guidelines provided
helped them to understand SNSs (p=0.002). Surveyors spent more time than staff preparing for the survey (p=0.000).
Surveyors thought the survey had less impact on patient care than did staff (p=0.030). Surveyors were less likely than
staff to agree that SNSs validated an organisation’s continuous improvement strategy rather than point-of-time
compliance (p=0.001), and that SNSs would be perceived by the public to be more credible than scheduled surveys
(p=0.012). Surveyors were less likely than staff to agree that SNSs should only be used when there is evidence that an
organisation is performing poorly (p=0.024). There were three contrasting points of view from the two groups of surveyors.
AGPAL surveyors were significantly more likely to agree that the guidelines provided helped them to understand SNSs
(p=0.040). Compared to organisational staff, ACHS surveyors were more likely to believe that SNSs support continuous
quality improvement (p=0.016) and that they reduce unnecessary costs incurred by the organisation when preparing for
surveys (p=0.031).
Conclusions:
SNSs are being adopted widely in accreditation programs, but we know little about participants’ views of them. This
research has provided insights into the complex activity of surveying. There was significant unprompted support from
study participants for SNS to be adopted by accreditation agencies, but the picture is more nuanced than appears. Views
about the overall impact of SNS were mixed, as were conclusions as to whether they validate organisations’ continuous
improvement efforts. These differences may relate to underlying perceptions. Are SNS to be used to reinforce a
‘compliance model of accreditation’, where an organisation fails or passes against a set criteria? Alternatively, should
SNS encompass a ‘continuous quality improvement model’, whereby those involved in the accreditation assessment
collaboratively review progress to identify gains and areas for improvement? The findings highlight the challenges faced
by accreditation agencies when considering change.
0174
An empirical comparison of performance on short notice surveys with advanced notice surveys in two
accreditation programs
1
2
2
2
Margaret Banks , David Greenfield , Max Moldovan , Jeffrey Braithwaite
1
2
Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia, Australian Institute
of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
Objective:
To compare performance of short notice surveys (SNSs) with advanced notice surveys (ANSs).
Methods:
Two independent studies examined the SNS methodology. The two accreditation programs assessed were: 1) the
Evaluation and Quality Improvement Program (EQuIP, 3rd edition) from the Australian Council on Health Care Standards
(ACHS); and 2) the Royal Australian College of General Practitioners (RACGP, 3rd edition standards) from the Australian
General Practice Accreditation Limited (AGPAL). We benchmarked 15 and 48 standards from the ACHS and AGPAL
accreditation programs respectively against the Australian Commission on Safety and Quality in Health Care’s nine
priority issues, developing a tool to facilitate the comparisons. Participating institutions were given two days notice of the
SNSs. The SNS assessments were matched to evaluations from the organisations’ previous ANS data. Data was
analysed using inferential and descriptive statistics.
Results:
Twenty healthcare organisations participated in the ACHS SNS trial. There were 13 organisations that did not assess
non-mandatory criteria in their previous ANS. Therefore from a possible 301 items there were 241 matched rating
assessments between the SNS and ANS. Agreement was reported for 192 (80%) with the aggregated Kendall’s
coefficient of concordance W=0.80 (p=0.000). There were 49 criteria ratings with different assessments. The SNSs
offered a more favourable assessment in 17 cases and less favourable in 32. Nineteen SNS assessments, while lower
than the ANS findings, were still above the accreditation threshold. Thirteen of the less favourable SNS assessments
were lower than the accreditation threshold; six of these corresponded to mandatory criteria, thus changing the
accreditation outcome (p=0.006). Nine of the less favourable 13 assessments were in the EQuIP ‘Clinical’ function
category and the remaining four spread evenly over the ‘Support’ and ‘Corporate’ areas.
There were seven general practices that participated in the AGPAL study. There were 304 matched assessments with
agreement across 261 (86%) criteria; the aggregated Kendall’s coefficient of concordance was W=0.52 (p=0.316). SNSs,
in contrast to ANSs, had fewer ratings that met the standards criteria and more ratings that were not assessed. The
previous ANS had assessed four organisations as meeting the accreditation threshold whereas the SNS trial evaluated
none as doing so (p=0.057). The SNS and ANS matched assessments demonstrated a high level of alignment (ranging
from 74% to 91%) against groups of standards when they were aligned against the ACQHC priority issues. However, the
SNS approach was more critical when assessing clinical issues than administrative requirements.
Conclusions:
The two independent SNS trials demonstrated good levels of agreement with the assessments from existing survey
method. In each trial there was a match of no less than 80% of the SNS and ANS evaluations. However, in both studies
the SNS approach produced more critical assessments than the ANS and the points of difference had a major impact.
The SNS has been more critical in assessing clinical standards, and significantly more organisations failed to meet the
accreditation threshold. The SNS trial may have uncovered limitations with current practice. Alternatively, implementing
the SNS approach may need further refinement. The SNS trial has highlighted that changes to existing accreditation
surveying practice can produce differing outcomes, and thus should be used with caution. Further research might target a
more comprehensive understanding of the effects of adopting SNSs.
0175
Identity check and patients’ satisfaction on the quality of ultrasound service, United Christian Hospital
SM Peter Yu, HY Miranda Lai, YH Joyce Hui, KM Lily Wong
United Christian Hospital, Hong Kong
Introduction:
Health care settings are complex and inherently risky and patient misidentification is the top health care risk. As patients
often see things that we busy healthcare providers do not, the conduction of patient satisfaction survey would help in
collecting patient feedback and revamping the current complaints system.
Objectives:
To evaluate the work flow of our ultrasound service and the adequacy of patients' identity check in the ultrasound
examination room hoping to minimize the patient misidentification incident. Patients' satisfaction to our service would also
be assessed.
Methodology:
Out-patients attending the radiology department of the United Christian Hospital for ultrasound examination were
randomly chosen and prospectively interviewed. They were asked about whether they have read the patient’s instruction
sheet before the examination and who they thought had performed the ultrasound examination. Patients were inquired
upon their satisfaction upon the quality of service provided using a 10-point-scale. The time duration patient needed to
wait for the examination in the radiology department was also audited. The adequacy in execution of identity check by our
staffs was also assessed.
Results:
A total of 110 patients were studied. An overall satisfaction score of 7 or above was obtained in 92.5% of patients.
Constructive comments on clarity of instructions, staff attitude, workflow and fixtures were collected. Only 70% of the
patients recognized that the examinations were conducted by radiologists. Twenty-one patients (19.1%) did not read their
instruction sheets prior to the examination. Patients needed to wait for an average of 33 minutes in our department for the
examination to be performed. An identity check of at least two patient properties was executed in 92.7% of patients.
However, requests for the actual presentation of Hong Kong Identity Card were made in only 19.1% of patients.
Conclusions:
The overall performance was satisfactory judged by our patients and adequate identity check was executed in our
department. Nonetheless, several potential areas of improvement were identified. Corresponding supervisory
enhancement and staff retraining programme can be made to simplify and unify our protocols and procedures, hoping that
our frontline staffs can deliver their service safely, efficiently and effectively. We plan to re-audit our ultrasound service in
future. All these help to reduce human errors and enhance patients' safety and public accountability.
0180
Incidence and preventability of adverse events in surgical patients in Monastir (Tunisia)
Mondher Letaief, Sana El Mhamdi, Wassim Kallel, Mouna Chaba
University Hospital of Monastir, Tunisia, Monastir, Tunisia
Objective: To determine the magnitude and the scope of adverse events (AE) for surgical patients in Monastir (Tunisia).
Methods: The methodology is based on a prospective descriptive study in the surgical unit in the university hospital of
Monastir (Tunisia). Patients enrolled in the study will be followed up prospectively. The identified adverse events during
the hospitalization will be included as well as those occurring prior to the index hospitalization in the same hospital.
Medical professionals have completed the screening guide for all the admitted patients included in the study by reviewing
the medical and nursing notes and conducting a staff interview with the head nurse or the physician. When there is at
least one of the 16 criteria in revue form 1 (RF1) present, the experts will proceed to the reviewing phase by the
completion of the revue form 2 (RF2). This need to be done by two reviewers: A trained surgical specialties for the
RF1and an expert physician completed, if necessary, the RF2. The admitted patients will be followed up until their
discharge from the hospital.
Results: A total of 600 patients were followed during 2010, among them 106 experienced one or more AE with an
incidence density of 14.6 events/1000 patients-hospitalization days. Unplanned admission within 12 months prior to index
admission was the most identified screening criterion (RR=8.1; 95% CI [5.9 – 10.3]).
Among the confirmed events 31% were judged to be highly preventable. The risk of an AE depended on the used
procedures (surgical and others invasive procedures) and increased with age, duration of surgery and length of hospital
stay. However, both genders experienced equal rates of AE.
Conclusion: The high AE rate for surgical procedures supports the need for monitoring and intervention
strategies. Prophylactic interventions could reduce the occurrence of AE in hospitals.
0182
Impact of a tool for structuring actions plans for patient safety: a randomized controlled trial
Sana El Mhamdi, Anthony Vacher, Jean-Luc Quenon, D'Hollander Alain
Coordinating Committee and clinical evaluation and quality in Aquitaine, Bordeaux, French Polynesia
Objective: To investigate the effectiveness of a tool for structuring action’s plans after in-depth adverse events analysis.
Methods: An experimental study was conducted. Participants were volunteers hospital risk managers, randomized in two
groups differed only in the allocation of the tool. The tool, developed from the model “DEPOSE” of Charles Perrow was a
seven categories grid conceived to facilitate the identification of problems and actions to implement. Each group
(intervention and reference) had to analyze and propose, in two measures, preventive actions for two scenarios of
adverse drug events. The first measure was realized without the tool and the second with the tool for the intervention
group.
The main outcome measure was the number of proposed actions identical to actions identified by a committee of eight
experts.
Results: In February 2010, 56 hospital risk managers were randomized. A significant difference in the mean number of
the differences of proposed actions (Measure 2 - Measure 1) was observed for the intervention group with a 1.3 actions
versus -0.6 for the reference group (p-value = 0.004). A linear mixed effects model for longitudinal data showed that the
scenario changed the effect of the tool on the proposed actions. The number of actions was significantly higher in the
intervention group with a difference of 2.4 actions (CI95%: 1.43 - 3.40, p-value < 0.001) for scenario No.1 and a difference
of 1.1 actions (CI95%: 0.02 - 2.00, p-value = 0.046) for scenario No.2.
Conclusion: Our results showed the effectiveness of the tool for the two analyzed scenarios. Its effectiveness on other
types of adverse events, its feasibility and acceptability by the risk managers should be examined before the widespread
of its use.
0185
Suggested Guidelines for ASA Physical Status Rating is Facilitating Classification Consistency in Group Practice
Hospitals
Ying-Hui Chen, Su-Zhen Wu, Chin-Jung Chen, Edmund Cheung So
Chi Mei Medical Center, Liouying, Tainan, Taiwan
Objective:
This project is to improve the consistency amongst different physicians’ approach of rating patients by the American
Society of Anesthesiologists physical status (ASA-PS) classification who are receiving pre-anesthesia visits and have
scheduled operations performed by separate anesthesia physicians in a group practice hospital.
Methods:
Due to a great discrepancy of ASA-PS rating by different anesthesiologists, we announced suggested guidelines about
rating ASA-PS for all of our anesthesia staff (http://blog.xuite.net/jenjer.chan/01/42553048). This guideline was produced,
with consensus, in our department meeting. Both Attending and Resident anesthesia physicians and nurses in our
hospital were asked to rate ASA-PS classification for 10 hypothetical clinical cases before the guidelines were announced
(pre-test) (http://blog.xuite.net/jenjer.chan/01/42552143). These hypothetical cases were first reviewed by two attending
physicians which have more than 20 years of working experience. In general, these hypothetical cases have no major
conflicts. The same survey was performed again after the guidelines were announced within the department 1 month later
(post-test). Statistics from the two tests were recorded and compared. Kappa statistic (k) was used to determine the
strength of agreement. In which k=0-0.2, k=0.21-0.4, k=0.41-0.6, k=0.61-0.8, and k=0.81-1.0 represented slight, fair,
moderate, substantial and perfect agreement respectively.
Results:
The response rate of our staff was 83%, 100% and 86% in attending physicians, resident physicians and nurses
respectively. Overall response rate was 86.9%. Of all the hypothetical cases presented, in both pre-test and post-test, 9
cases received three different ASA-PS class grading and 1 case even had 5. Judging by Kappa statistic, there is light
agreement (k=0.16) in the pre-test. Consistency was improved in the post-test (k=0.37), but not significantly as there is
only fair agreement. For the inter-raters variability, F-test of the 10 hypothetical cases between pre-test and post-test
showed that the p-values of 7 cases were less than 0.05 (showing considerable consistency) and 3 cases with its p-value
more than 0.05.
Conclusions:
ASA-PS is widely used by anesthesiologists to evaluate anesthesia risk. Different ASA-PS rating of patients still bothered
clinical practice especially when the staff performing the pre-anesthetic rating is not the one performing the anesthesia.
The major problem is that these two physicians might have different opinions on the ASA-PS rating. Within our 10
hypothetical cases, most showed improved consistency after the announcement of the suggested guidelines but some did
not. This study shows that our rating suggestion guideline gave minor assistance in improving consistency. ASA-PS rating
is still greatly variable amongst different anesthetic staff, but from the patients point of view and for the improvement of
medical quality, it is better if the assessment of ASA-PS is standardized. Further work is needed to achieve so.
0187
Measuring Duration of Preparation Towards MSQH Accreditation for Public and Private Hospitals in Malaysia
Rozana Osman, Saifulhazmi Salihin
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective
To evaluate the duration of preparation towards MSQH accreditation from the date of accreditation training until the date
of accreditation survey for public and private hospitals in Malaysia.
Methods
Data on the number of hospitals that have undergone MSQH accreditation training and surveys from 2008 until 2010 were
collected. From this, the average time taken by the hospitals to prepare towards accreditation survey were noted.
Comparisons were then made between public and private hospitals.
Results
The results are shown below:
Figure 1
Figure 2
It is noted from figure 1 that as the hospital increases in the number of cycle, the shorter time it will take in preparing
towards the MSQH accreditation survey. The graph in figure 2 demonstrates that public hospitals with specialist took
longer time to prepare towards accreditation compared to the public hospital without specialist.
Conclusion
(1) The time taken for preparation towards MSQH accreditation decreases correspondingly with the increase in the
accreditation cycle. Evidently, this reflects the hospital’s experience, coupled with the expertise and knowledge that
enabled them to reduce the time taken in preparing towards MSQH accreditation.
(2) Public hospitals took longer time to prepare towards MSQH accredited hospital compared to private hospital as most
private hospitals are independent and have autonomous decision making.
(3) Public hospitals took longer time to prepare towards accreditation due to factors such as high staff turn over and
frequent changes in leadership.
(4) Public hospital without specialist took lesser time to prepare towards MSQH accreditation survey compared to public
hospital with specialist due to the complexity and the expanded services offered by specialist hospital.
0188
Lessons Learned from the Surveillance of Clostridium difficile Infection at a Tertiary Care Hospital
1
1
2
1
Anjum Khan , Patricia McKernan , Dylan Pillai , Roslyn Devlin
1
2
St Michael's Hospital, Toronto, Canada, Public Health Laboratory-OAHPP, Toronto, Canada
Objective:
To describe the investigation of deviations, analysis and lessons learned from surveillance of Clostridium difficile infection
(CDI) at St. Michael’s Hospital.
Methods:
Public Reporting of CDI in Ontario hospitals began on September 2008. In December 2009, the Ministry of Health and
Long -Term Care (MOHLTC) revised and released new and more sensitive definitions for notification of CDI clusters and
outbreaks to optimally trigger action and dialogue between Public Health and the hospitals for the outbreak investigation
and management.
th
Based on these new definitions our hospital was identified by MOHLTC to be above the 80 percentile for comparator
hospitals, having 13 Hospital Acquired (HA) cases of CDI in March 2010 (Figure 1). Cases were defined as HA based on
standardized definitions by MOHLTC. CDI rates per patient day were plotted on a control chart. Investigation included
careful review of all CDI cases for the underlying risk factors, antibiotic exposure histories, and their temporal relationship
for any possible epidemiological links. Pulse Field Gel Electrophoresis (PFGE) was done to establish strain relatedness.
Enhanced Infection Control Measures (EICM) included strict barrier precautions, reinforcement of hand hygiene practices
with soap and water, enhanced environmental cleaning and equipment disinfection on the affected units.
Results:
In March 2010, we had 13 HA cases of CDI distributed on 6 units. CDI rate for March was greater than 2 standard
deviations above our baseline rate. Two units had 3 cases each, one unit had 2 cases and 2 units had 1 case each. All
patients had underlying comorbidities and antibiotic exposure history. PFGE revealed multiple CDI strains in this cohort
including 2 cases of North American Pulsed Field type 1 (NAP1). There was evidence of nosocomial transmission
between 2 patients on 2 different units based on similar PFGE patterns and epidemiological links. Both times, the index
case had relapsing diarrhoea and CDI and transmission occurred with non-NAP1 strains. 4 cases (30.76%) of CDI from
this cohort expired, but in only 1 case was CDI the contributory cause of death. Patients who expired were more elderly
(average age 73.5, range 60 - 81 years) and none of expired patients had the NAP 1 strain. Following the implementation
of EICM, our rates returned to baseline.
Conclusions:
The new outbreak definitions from MOHLTC are more sensitive and aid in early detection and prompt management and
control of CD. Identical PFGE patterns and evidence of temporal relationship on 2 units indicated possible transmission
from 2 patients with relapsing diarrhoea. The hospital infection control policy was revised to incorporate maintenance of
contact precautions on patients with relapsing diarrhoea and CDI even if their symptoms are resolved. EICM and
environmental cleaning worked to bring the CDI rates back to baseline. As a result of this investigation, a quality
improvement project was undertaken to enhance the expected standard of environmental cleaning.
Although antibiotic stewardship has been shown to be an important component of outbreak management, this deviance
was rapidly controlled by EICM alone directed at interrupting the horizontal spread.
Figure 1
Public Reporting
started Sept 2008
Cluster investigation March 2010
after Revised Notifiication Thresholds
from MOHLTC
Revised notification
threshold definitions
released in Dec 2009
0189
An Audit on Length of Stay & Outcomes of Major Trauma Patients Resuscitated in Regional Hospital before
Secondary Trauma Diversion
1
1
2
1
Chun-tat Lui , Kwok-leung Tsui , Chu-leung Lau , Yiu-hang Simon Tang
1
2
Tuen Mun Hospital, Hong Kong, Pok Oi Hospital, Hong Kong
Objective:
To shorten the length of stay (LOS) and to improve the outcomes of major trauma patients transferred from the Accident
and Emergency Department (AED) of a regional hospital to trauma centre i.e. undergoing secondary trauma diversion
(STD).
Methods:
Data based on local trauma registry during the period from November 2007 to December 2010. All major trauma patients
(defined as Injury Severity Score, ISS > 15) undergoing STD were included. Specific causes of the delays were identified
by expert panel, including prolonged X-rays waiting time, performing unnecessary investigations, prolonged ambulance
response time, or sometime the medical team just forget about the importance of the time. The time pledge of <40
minutes before STD was agreed as the benchmark of service based on the golden hour of trauma management and the
travel time from regional hospital to trauma centre (around 20 minutes). An intervention program was commenced in July
2008 with specific improvements to prevent unnecessary delay, including
(1) Installation of wall mount clock & digital alarm every 20 minutes
(2) Design of clear protocol and checklist for trauma management
(3) Reduction of unnecessary investigations that would not affect patients’ management in the regional hospital
(4) Collaboration with the X-ray department for prioritization of trauma patients, utilization of filmless radiology and
reduction of time spent on films-printing, and acquisition of digital images in the receiving unit
(5) Well designed transferral plan of arranging ambulance and pre-packed transfer kit specified for trauma
(6) Training sessions and materials for medical and nursing staffs with feedback and reinforcement channels.
We conducted a detailed review to ensure that appropriate management had been provided without compromise because
of the new service benchmark. Two time periods [before(November 2007 to June 2008) and after (October 2008 to
December 2010)the intervention] were selected for comparison with a washout period of 3 months from July to
September 2008. The first outcome measured was the percentage of cases meeting the time pledge. The other outcomes
measured were the LOS before STD and the percentage of cases with a significant deterioration of physiological
parameters, defined as reduction of Revised Trauma Score (RTS) for more than 3 points on arrival to trauma centre.
Results:
A total of 51 cases were identified with 11, 11, 29 cases occurred in pre-intervention, washout and post-intervention
periods respectively. The baseline characteristics (age, gender and ISS) were comparable between the pre-intervention
and post-intervention groups. In the pre-intervention period, 9.1% met the time pledge and 45.5% had deteriorations in
RTS. In the post-intervention period, a significantly higher percentage of cases (58.6%, p=0.005) met the time pledge and
a significantly lower percentage of cases (13.8%, p=0.047) had deteriorations in RTS The median LOS pre-intervention
was 77.0 minutes and shortened to 43.0 minutes in the post-intervention period (p=0.02).
Conclusion:
An intervention program with a pre-set time pledge can reduce the occurrence of prolonged LOS in regional AED and the
subsequent deteriorations in RTS for the major trauma patients not undergoing primary trauma diversion. Further audit
should be conducted to ensure the quality of care as provided by regional centre will not be undermined because of the
urge to meet the “40-minutes service pledge”.
0190
dBasePNP - Innovative Primary Nurse Program designed to Save Nursing Time and improve documentation
Keng Hang Wong, Kanny Kwong, Kat Wong
Castle Peak Hospital, SAR, China, Hong Kong
Introduction:
The initiative of applying information technology through self-designed Data Base Primary Nurse Program (dBasePNP) in
5 wards of a Department proved to be effective and leads to wide implementation to the whole hospital wards of CPH.
The program eliminated lot of non-value added time in repeating paper work and extensively improved the efficiency of
data retrieval and documentation management. The program helped shifting valuable nursing time to direct patient care: saved 90 min. from 120 min. of time (75%) in writing up comprehensive care plan and 30 min. from 50 min. of time (60%)
in nursing discharge summary. The positive effects are expected to be more significant upon wide implementation of the
program where sharing of information becomes part of the accepted practice among nurses in the system.
Objectives:
To provide an effective and efficient platform to formulate nursing care plan or produce documents related to patient's
care delivery with good quality printouts to improve communication and documentation.
Methods:
1.
dBasePNP system developed in 2007 and adopted in 5 wards of Forensic Department in 2008.
2.
User friendly and patient care focused version enhanced in 2010.
3.
Widely accepted by frontlines nurses and endorsed for wide implementation by Hospital Manager in 2010.
4.
Task force for on-going overall project monitoring activated.
5.
Wide implementation in the Hospital in 2011.
Results:
A satisfaction survey conducted in December 2010 in 5 Forensic Wards showed the majority are satisfied to the program
mainly on time saving and ease of use:
User’s Satisfaction Survey on dBasePNP 2010
1
2
3
4
5
(most satisfied)
6
(least satisfied)
Time Saving
20
33
8
1
1
Ease of Use
19
30
13
2
Function
14
38
10
2
Security
13
23
23
5
Reliability
11
32
19
2
Care Plan Content
10
24
21
5
3
Technical Support
7
18
24
7
2
Overall Rating
14
33
16
1
Conclusion:
The project has achieved its objectives in saving nursing time and improving documentation quality. Seamless care is
ensured through better communication among disciplines by means of well structured and standard system. Taking into
consideration the average admission number is 2333 per year (2006-2010), it is estimated that the saving of 120 minutes
on every one case will amount to 4666 hours per year when the program is fully implemented in the coming years.
0191
Quality and Safety enhancement on Total Joint Replacement (TJR) through Clinical Pathways in Kowloon Central
Cluster (KCC)
Wang Kam Fung Oscar, Lam Kit Lun, Tsang Ka Kit
Hong Kong Buddhist Hospital, Hong Kong, China
Objective:
Developing a multidisciplinary clinical pathway for those patients with TJR within KCC of Queen Elizabeth Hospital (QEH)
& Buddhist Hospital (BH) in order to
•
Enhance safety and standard practice in terms of minimization of post-operative complications
•
Improve quality and continuity of care between 2 hospitals
•
Decrease the length of stay
Method:
In order to reduce the waiting time for patients to have joint replacement surgeries, a joint replacement centre (JRC) has
been established in BH of KCC in Dec 2010. BH is a community hospital and the scope of in-patient clinical service
mainly focuses on medical, convalescence, hospice and oncology. Orthopedic service is unfamiliar to nurses over there.
For the preparation of the JRC establishment, two clinical pathways (CPs) had been developed. It aims at maintaining the
quality and standard of care, minimizing the post-operative complications and decreasing the length of stay (LOS).
Besides, improving the multidisciplinary communication to facilitate the quality of care and make better use of resources.
The development and evaluation of the two multidisciplinary clinical pathways underwent in 2 stages. In the first stage,
CPs were developed in Orthopedic and Traumatology (O&T) department of QEH since May 2010. During July to
st
September 2010, the 1 stage clinical audit has been carried out to all TJR patients to see the effectiveness and
outcomes of clinical pathways by multi-disciplinary team including orthopedic surgeons, anesthetists, nurses,
nd
physiotherapists, and social workers. After the establishment of JRC, the 2 stage clinical audit has been carried out to all
TJR patients, including all clinical admitted patients in BH and transferred in patients from QEH from Dec to Jan 2011.
Results:
st
During the 1 stage audit period, there was no post-operative complication recorded except 1 male patient suffered
duodenal ulcer in August 2010. Multi-disciplinary compliance rate of clinical pathways was high ( 98 %). One year before
the establishment of CPs, over 90% patients had LOS equal or greater than 14 days. After the implementation of CPs
from July to December 2010 in QEH, 93 % and 66 % of patients were less than 14 and 11 days of hospitalization
st
respectively. Moreover, the CPs were simplified and amended after the 1 stage of audit so as to enhance our quality and
standard of practice.
nd
In the 2 stage audit period from Dec to Jan 2011 in BH, there was no serious surgical complication developed. 3
patients transferred back to QEH in the post-operative period due to suffered severe delirium, gastritis and chest pain
respectively. Multi-disciplinary compliance rate of clinical pathways was 98 %. 83 % and 67 % patients were less than 14
and 11 days of hospitalization respectively. There were 5 patients transferred from QEH for rehabilitation. 4 patients were
discharged within the time frame of clinical pathways except 1 male patient discharged larger than D14 for stair training.
Conclusions:
Clinical pathways can standardize and co-ordinate the practice between QEH and BH within the same cluster. It shows
that CPs can enhance the safety practice, improve the quality and continuity of care. With the standard enhancement, it
can further decrease the average LOS so that cost containment is achieved.
0193
The project of promoting the completeness of coronary syndrome patient education in the ICU
Ya-Ting Ke, Chuen-Yu Jung, Shen-Ling Liou, Shiau-Ling Shiu
CHI-MEI MEDICAL CENTER, Tainan, Taiwan
Object：Used DVD information system to strengthen patients’ concept and self-caring abilities and then raised the
completeness and satisfaction of patient education of the unit
Method：Our unit was heart internal medicine ICU. Myocardial infarction was the first disease in the unit for five years,
and most patients had cardiac catheterization surgery. Nurses took much time to care patients while they had little time to
perform patient education for patients and their family members, so the completeness rate was only 0% to 10% from April
to May in 2008. Therefore, we proceeded quality index monitor on June in 2008, took project management tactic, and
used P-D-C-A model to improve the procedure. The first step was using questionnaire, clinical examine, anamnesis
general survey to find the reasons and order incomplete items so that we could improve the low rate. The second step
was taking four measures：1. Correcting patient instructions and guide 2.Making a short film and DVD of patient
education 3.Establishing patient education rules, standard, quality control of the unit 4.Holding in-service education and
ward conference guidance to construct the atmosphere of patient education.
Result：We found that the reasons leading to the low rate were as follows：nurses thinking that they had not enough
time to perform patient education, the content of patient instructions and guide were old and incomplete, fewer assistant
tools, and lacking the atmosphere of patient education in the first step. In the second step, through the four measures, the
completeness rate raised to 70%, the whole satisfied rate raised to 90%, and the average scare of self-caring concept
and ability after having cardiac catheterization surgery was over eighty points from June 2008 to February 2009.
Conclusion：We found that it was ignored when patients need some care information because nurses’ clinical work was
busy and lacking patient education tools. We could examine the patient education tools of the unit, update and interest its
content by making patient education DVD, and then construct the atmosphere of patient education for whole staff. It
offered notice during the process of patients examining, disease diagnosis, care information after surgery and so forth so
that the concept of disease and patients self-caring could be increased, reduced complications, raised the level of health
control beliefs, helped patients have motive to change their life styles, and finally lessen infarct incidence. It could save
time and reduce nurses’ workloads by DVD, and create a nurse-patient win-win situation.
Key words：Patient education DVD, myocardial infarction, self-caring after having cardiac catheterization surgery
0194
Implementation of an innovative “Audible Drug Label” to enhance Medication Safety
1
2
2
1
Cheuk-ming, Oliver CHAN , Kitty WOO , Agnes TAM , Bonnie WONG
1
2
New Territories West Cluster, Hospital Authority, New Territories, Hong Kong, Pok Oi Hospital, Hospital Authority, Yuen
Long, Hong Kong
Objective: This project aims to enhance the medication safety of an “Emergency Drug Cupboard Room” through visual
and audio emphasis toward staff on the vital drug information.
Background: (1) A medication error is any preventable event that may cause or lead to inappropriate medication use or
harm to a patient [1]. Amongst them, the administration of a drug that may evoke an allergic reaction to a patient is one of
the most serious consequences. Various causes contribute to different medication incidents, some examples are the
confirmation bias and knowledge gap within the clinical team. In addition to the development of guidelines and policies,
adoption of alert systems as a risk reduction tool is particularly useful for those veterans experienced in their routine work.
(2) There are many alert systems for the prevention of medication errors. The adoption of “Tall Man Letters” for the LookAlike drug names [2], and the modification of drug labels to highlight the essential information are implemented in most
hospital settings. Meanwhile, these visual emphases could be easily desensitized, and are difficult to prevent those
incidents caused by the knowledge gap, such as the failure to correlate an antibiotic to a combination of broad spectrum
antibiotic group during the prescription and administration. (3) The Pok Oi Hospital (POH) of the Hong Kong Hospital
Authority (HA) operates over 400 acute hospital beds. Besides the main pharmacy managed by Pharmacists and
Dispensers, there is a “Self-service” named as Emergency Drug Cupboard Room (EC), operated by whole hospital wards
during after pharmacy hours and drug items are replenished daily by the Pharmacy Department, which stocks the
commonly used drugs and antibiotics.
Methods: The M&G Department and the Pharmacy Department in collaboration with the Quality & Safety (Q&S) Division
has initiated a quality improvement project to enhance medication safety. Since November 2010, an “Audible Drug Label”
has been installed to the drawer for the storage of “Augmentin Oral tablet” in the EC. The drug “Augmentin” is a
combination of Amoxicillin and clavulanate potassium, also a known high allergy risk medication [3]. This electronic device
is designed and assembled in the in-house workshop of the hospital and the cost is less than $10 (USD). The photo of the
device is shown in Figure 1. It is powered by replaceable batteries. The “light sensor” would be activated when the drawer
was opened and a 10-second pre-recorded script (alerting note) would be played from the speaker. 3 key messages are
included in the alerting note, including the drug name (i.e. augmentin), the antibiotic group (i.e. Penicillin) & a reminder on
confirmation of the patient allergy history before the administration of the drug.
Results: Since the implementation of the “Audible Drug Label”, the four M&G wards achieved the target of zero
medication error related to giving Augmentin to patients who are allergy to Penicillin group after Pharmacy hours. The
additional information (i.e. antibiotic group and the reminder) provided definitely addressed the knowledge gap which is
one of the common causes leading to the medication incidents. The audible message could be re-recorded easily with
different voices to prevent desensitization of the audio emphasises.
Conclusion: It is concluded that the combination of visual and audio emphasis to provide essential information and
reminder to the staff during their routine work is a practical approach to enhance medication safety. The application of this
“Audible Drug Label” is extendable, and to be implemented in other high risk areas such as the Dangerous Drug (DD)
Cabinet.
Reference:
[1] http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048644.htm
[2] http://www.ismp.org/tools/tallmanletters.pdf
[3] http://www.ha.org.hk/haho/ho/psrm/COPYSESUE_Annual_Report_2011.pdf
0197
Introduction of C-Arm Fluoroscopy Successfully Enhancing Patient and Staff Safety in Double Contrast Barium
Enema
Chun Yat Law, Chun Wai Wong, Ming Kay Chu
Kwong Wah Hospital, Kowloon, Hong Kong
Introduction
Double Contrast Barium Enema (DCBE) is the most commonly used radiological investigation of the entire colon in Fecal
Occult blood test (FOBT) positive individuals for its relative low cost and high accessibility, and in fact about 70% of the
fluoroscopic examinations performed in KWH are DCBE. However, traditional fluoroscopy procedures impose potentially
high OSH risks on patients and staff. With the introduction of C-arm fluoroscopy and the subsequent new protocol of
DCBE to KWH since 2008, patient and staff safety have been significantly improved.
Objective
This exhibit aims at demonstrating improvement in patient and staff safety upon introduction of new C-arm Fluoroscopic
Unit in performing double contrast barium enema (DCBE).
Methodology
Previous Practice – DCBE by Traditional Fluoroscopy Unit
Using traditional fluoroscopy unit for DCBE requires at least 7 films, which could only be managed near the x-ray tube
head and thus implied high risk of radiation hazard to staff. Moreover, patients were needed to be positioned to specific
postures for imaging, which imposed greater difficulties and more manual handlings to our colleagues especially in
assisting physically weak patients. Such procedures created potential risks to the safety of the staff involved, such as
sprain of waist and back, and to the patients who might fall during the process. Furthermore, frequent transportation of
heavy film cassettes to the dark room imposed heavy load of manual handling activities.
New Practice - DCBE by New C-arm Fluoroscopy Unit
With the aid of the wide range movement of the C-arm unit, the need for moving patients for posturing is reduced, which
eventually enhances patient’s safety and comfort. Film cassette is no longer needed as images are digitalized. The
radiation exposure time of staff is shortened since the machine can be controlled in a well-protected control panel, instead
of standing near to the x-ray tube.
Results
With the use of C-arm fluoroscopic unit, the following benefits are achieved:
1. Enhancing patients’ safety and comfort;
2. Reducing potential OSH risks of staff on manual handling and radiation hazard;
3. To path the way towards filmless digital hospital
Conclusion
C-arm fluoroscopy was introduced to KWH in 2008 as part of the hospital medical equipment replacement plan. The new
design and procedures have improved image quality with ease of operation. Most importantly, such change brings
enhancement of patient safety and reduction of staff OSH risk, which are essential considerations in future
purchasing plan.
0199
Re-design the patient delivery process in a severe learning disability hospital in Hong Kong
Tang Sau Kuen Frances, Cheung Wing Hing, Leung Fuk Tai Sabina, Tso Steve
Siu Lam Hospital, Hong Kong, China
Objective:
This project is to reduce the incidents of staff’s injury on duty by re-designing work process in delivering patients for
training from ward to training unit.
Method:
Effective work process in health care provision not merely enhances quality of care for patients but also ensures safe
occupational health for the healthcare workers. Continuous quality improvement through lean management can facilitate
the organization to find waste and transform it into value-added output.
Severe learning disability patients in the hospital received social education training by 3 team of staff of the training unit
after they were escorted to the classrooms of the unit from wards by the staff. The staff members would help them from
put on clean clothes and lift wheel-chair bound patients onto the wheelchair or special made chairs before escort.
Incidents related to injury on duty of staff occurred during lifting and delivering process increased in 2009. Total man-day
loss was 4.2%. The project was launched to re-design the process by adopting the lean improvement to define, measure,
analyze, improve and control the problems. Process mapping showed time wastage in the delivery process. Spaghetti
diagram showed the overlapping of patient flow in escorting round. Root cause analysis through the lean process found
that the causative factors were division of labour and uneven work distribution among staff, time wastage in waiting
leading to a longer delivery process; and heavy workload of staff within a short period of time.
The improvement project was fully implemented in June 2010 after a pilot study. Lean improvement tools were adopted to
reduce waste of waiting and streamline work process in several aspects. Staff members were re-deployed with evenly
distributed workload (heijunka) and regular job rotation. Workloads of wards were re-allocated to each team to reduce
work overlapping. More escort rounds in the delivery process and reduction of patient’s volume load in each round could
maintain the staff to patient ratio to 1:1. Visual reminder was used to indicate manpower requirement for lifting individual
patients.
Result:
The outcome showed significant improvement. There was no injury on duty related incident reported. Man-day loss of
staff was reduced to 0%. Organization could save cost on injury on duty compensation. Patient’s training activity could be
enhanced as time wastage in waiting could be reduced in the delivery process. Both patient safety and staff occupational
safety and health could be ensured as there was sufficient staff in the delivery process. Nursing supervision in escorting
process could be enhanced. Mutual co-operation and communication among staff could be maintained as team work
process was re-integrated. Clear communication between the training unit and ward staff could be achieved as there was
no overlapping work between the teams.
Conclusion:
With the help of a few lean tools, total man-day loss was reduced from 4.2% to 0% without the need for additional
resource. Safe and effective working environment are the ultimate goal in the healthcare service. Any redundancy in the
process should be eliminated to restore its efficacy and transform it into relevant added values. The project can attain the
objective to an extent that organization and people in it can benefit from the lean improvement initiatives.
0201
Measuring Patient Safety Culture in Tertiary Hospital, Saudi Arabia
Yusuf Ahmed, Hisham Aljadhey, Basmah Albabtain, Sinna Alaqeel
King Saud University, Collage of Pharmacy, Medication Safet Reseach chair, Riyadh, Saudi Arabia
BACKGROUND:
Safety culture is a set of variables such as attitude, beliefs, perceptions, and values that healthcare workers share to
ensure patient safety, implementation and practice of safety culture minimizes the medical errors and improves patient
treatment outcome. To our knowledge in Saudi Arabia no comprehensive studies were conducted to assess the attitudes
of healthcare professionals toward patient safety.
OBJECTIVES:
To assess the culture of safety for nursing staff in a tertiary teaching hospital in Saudi Arabia
METHODS:
Cross-sectional survey was conducted between May to August 2010, in 800-bed tertiary hospital in Riyadh, Saudi Arabia.
We surveyed 492 nurses using validated instrument the Safety Attitudes Questionnaire (SAQ). SAQ assesses safety
culture across six factors: teamwork climate, perceptions of management, safety, stress recognition, job satisfaction, and
working conditions. Respondents could potentially score from 5 to 1 on a factor score. Scores ≥4 (most favorable), score
between 4 - 3 their attitudes are (slightly favorable), score of < 3 but > 2 (unfavorable), and score between 2 - 1(very
unfavorable).
RESULTS:
Survey from 492 King Khalid’s University(KKUH) hospital nurses, were included in the analyses. The age of participants
were as follows: <30years 23.2%, 30-39years 36.9%, 40-49years 20.7%, 50 years or more 19.1%. Of these, 92% were
Female. The mean scores for all scales were in general slightly to most favorable attitudes, 4.2 for teamwork climate, 4.17
for safety climate, 4.54 for job satisfaction, 3.26 for stress recognition, 3.8 for perceptions of management, and 4.37 for
working conditions.
CONCLUSION:
This is the first comprehensive study to measure the culture of safety toward patient safety in Saudi Arabia. Our study
shows that the nursing staff in KKUH in Saudi Arabia hospital have positive attitude toward patient safety and this
indicates that KKUH is committed in addressing patient safety.
Further studies are needed to compare the culture of safety between hospitals in Saudi Arabia and between health care
professionals.
0202
A Preliminary Study of Adverse Drug Events and Medication Errors in Saudi Arabia
Hisham Aljadhey, Mansour Adam, Ahmed Mayet, Mashael Alshaikh
King Saud University, Medication Safety Research Chair, Riyadh, Saudi Arabia
Background: The incidence of adverse drug events in hospital setting was estimated in the United States and other
countries. In Saudi Arabia studies are short to investigate the incidence and outcomes of these events.
Objectives: To assess the incidence of adverse drug events (ADEs) in a teaching hospital in Saudi Arabia.
Methods: A Prospective cohort study conducted in 800 beds tertiary teaching hospital. The study included 977 patients
admitted to two medical, one surgical and two intensive care units (ICUs) over four months. The main outcome measures
for this study was the incidence rate of ADEs, potential ADEs and medication errors and it is preventability and severity.
Incidents were identified by three pharmacists who reviewed patients charts, laboratories and prescription orders. One
physician and one senior clinical pharmacist reviewed the incidents to determine whether they were ADEs, potential
ADEs or medication errors. Incidents that did not fall under any of these categories were excluded by reviewers.
Results: Over four months, pharmacists identified 361 Incidents in 261 patients, out of which 281 incidents in 208
patients accepted by the reviewers. A total of 83 ADEs occurred in 68 patients (incidence: 8.7 per 1000 patient-days and
8.5 per 100 admissions) with a higher rate in ICUs (incidence: 20 per 1000 patient-days and 21.1 per 100 admissions)
compared to other study units. Among ADEs 6% were rated as life threatening, 34.9% as serious, and 59% as significant.
Preventable ADEs were 30.2%. One hundred ninety eight medication errors in 154 patients were identified (incidence:
20.7 per 1000 patient-days and 20.2 per 100 admissions). Among medication errors 132 were potential ADEs (incidence:
13.8 per 1000 patient-days and 13.5 per 100 admissions) with a higher rate in ICUs (incidence: 30.8 per 1000 patientdays and 32.6 per 100 admissions) compared to other study units. Among potential ADEs 1.5% were rated life
threatening, 43.9% serious and 54.5% significant. Intercepted potential ADEs were 36.4%.
Conclusions: The incidence of ADEs in this hospital was similar to that reported in the USA and less than that reported
in Japan, however the rate of medication errors was higher. This is a preliminary study of one hospital and part of an
ongoing multicentre national study that include other three hospitals representative of Saudi Arabia hospitals.
0203
Adherence to Institute for Safe Medication PracticeLabel Guidelines in Riyadh Hospitals, Saudi Arabia
Yusuf Ahmed, Hisham Aljadhey, Salma Alkhani
King Saud University, College of Pharmacy, Medication Safety Research Chair, Riyadh, Saudi Arabia
Background:
Medication labels in the health care setting are used to communicate medication related information necessary to
ensure safe use of medications. The Institute for Safe Medication Practice (ISMP) released the Principles of designing a
medication labels for Inpatient and Community.
Objectives:
1. Evaluate the overall compliance in medication labels in the city of Riyadh hospitals, Saudi Arabia in reference to
ISMP principles of designing a medication label.
2. Compare level of compliance in medication labels between hospitals of the five different healthcare sectors
Methods:
This was a cross-sectional study; ISMP guidelines for labels are utilized to design a data collection tool. Five different
labels were included in the study; Community and mail order, Intravenous piggyback, Oral liquids, Oral solids and
Injectable syringes.
Results:
The overall compliance level of Intravenous piggyback, oral solids and oral liquids medication labels, were 73.02%,
67.23%, and 60.65% respectively, where medication labels for community and Injectable syringes had lower compliance
levels, 50.04% and 46.40% respectively
Label format, contents, instructions, and abbreviations suctions had acceptable and good compliance, the drug name
section assessment showed low compliance (46.32%).
Of the five major health sectors medication label compliance, Referral and Military service hospitals are leading
medication label compliance for following ISMP guidelines. Autonomous and Ministry of health (MOH) hospitals, ISMP
recommendation adherence remained low.
Conclusions:
This is the first study to assess ISMP recommendation’s adherence in Saudi Arabia; our results suggest that labeling
system needs improvement to prevent medication errors.
0204
The Impact of Medication Discharge Counselling by Pharmacist on Adverse Drug Events and Patients
Adherence
Sami algahmdi, Hisham Aljadhey, Abdulkareem Albekairy, Mansour Adam
King Saud University, Medication Safety Research Chair, Riyadh, Saudi Arabia
Background:
Patients who discharged from the hospital often experience multiple changes in medication regimens that lead to
adverse drug events (ADEs), poor adherence, poor treatment outcomes, and increased health care cost.
Objectives:
To assess the impact of discharge counselling provided by pharmacist on ADEs and patient adherence.
Methods:
A prospective observational study was conducted for 200 patients who discharged with more than three medications from
the internal medicine wards of one major hospital in Riyadh, Saudi Arabia during 3 months. Patients in the counselling
group received pharmacist counselling at the time of discharge and follow-up telephone calls two weeks later. Patients in
the non-counselling group received usual counselling by nurses. Our interventions focused on patients counselling about
medications regimens, indications, directions, and potential side effects. The study outcomes were the rate of ADEs and
the level of patients’ adherence to medications.
Results:
Outcomes were assessed for 175 patients based on the inclusion criteria. Twelve patients from the counselling group
and 13 patients from the non-counselling group could not be contacted two weeks after discharge and therefore, were
excluded from the final analysis. ADEs were detected in 24.1 % of patients in the non-counselling group and 2.3% of
patients in the counselling group (P<0.001). The mean total score for medications adherence was 4.8 in the counselling
group and 4.3 in the non-counselling group (P<0.001). Patients with less number of medications had better adherence 0.18(-0.03 - 0.01) P =0.023.
Conclusions:
Pharmacist intervention on discharge has shown a positive impact on patient outcomes. However, a larger
epidemiological study is needed to confirm this finding.
0206
Waiting time reduction for electrolysis surgery in trichiasis and distichiasis
Andy Cheng, Hunter Yuen, Noel Chan, Ben Lam
Hong Kong Eye Hospital, Hong Kong
Objective:
The aims of this project are to identify factors that contribute to the long waiting time for electrolysis surgery in our hospital
and to formulate solutions that may help reduce the waiting time.
Methods:
Trichiasis (posterior misdirection of lashes) and distichiasis (abnormal row of lashes) are common eyelid abnormalities
which may cause chronic ocular irritations, corneal erosions and ulcerations. In longstanding cases, pannus formation and
corneal scarring may ensue which may cause permanent visual impairment. One of the established treatments of these
conditions is electrocauterization of the lashes. The waiting time for electrolysis surgery was previously very long in our
hospital. The aims of the current project are as stated above. This is one of our hospital’s quality improvement projects
utilizing the Lean Six Sigma approach. The Define-Measure-Analysis-Improve-Control (DMAIC) methodology was used.
The whole process of electrolysis surgery, from listing of surgery in our outpatient department (OPD), follow ups before
surgery, performing surgery, to the end of the procedure was mapped out. Current state data was collected from records
of all patients undergoing electrolysis surgery alone between Jan 2009 and Mar 2010. Waiting time for surgery, number of
follow-ups, need for epilation in OPD before surgery, surgical outcomes and complications were reviewed. Factors and
non-value added activities contributing to the long waiting time were identified and eliminated if possible. Value-added
activity (provide training platform for staff members) was also introduced. Cross department liaison with rearrangement of
workflow was performed so as to reduce the waiting time for electrolysis surgery. A pilot implementation of the control
measures was introduced since Jun 2010. Results of patients undergoing electrolysis between Jul 2010 and Sep 2010
were compared to those before implementation of control measures.
Results:
Thirteen patients were identified for the current state analysis. The mean waiting time for electrolysis surgery was 373
days. On average, patients required 2 follow-ups and 2 OPD epilations before having electrolysis. Main factors
contributing to the prolonged waiting time included competing need for operating theatre, lack of regular electrolysis
sessions and reluctant of surgeons to perform electrolysis in their surgery list. To overcome these problems, regular
electrolysis sessions were introduced in treatment room (rather than in operating theatre) and training was provided to
junior staff members so as to increase their participation. After pilot implementation of the control measures in the first 3
months, the mean waiting time was 42 days (14 patients) (p=0.001). Less than one follow-ups and OPD epilation was
required before electrolysis. No difference in terms of short-term surgical success (p=0.12) and safety (p=0.70) was noted
with such change of practice. Long-term results in terms of recurrence rate of the conditions are now pending.
Conclusions:
By using the DMAIC approach, factors contributing to the long waiting time for electrolysis in our hospital were identified.
By rearrangement of workflow and elimination of non-valued added activities, we were able to significantly shortened the
waiting time, lessen the follow-ups and OPD epilation before surgery, which essentially save valuable time and resources
for both patients and our hospital.
0208
Epidemiology of Hospital Falls on Acute Care Wards in Japan
1
2
3
2
Buichi Tanaka , Mio Sakuma , Masae Ohtani , Takeshi Morimoto
1
2
Tenri Yorozu Soudansho Hospital, Tenri-shi, Nara, Japan, Center for Medical Education, Kyoto University Graduate
3
School of Medicine, Sakyo-ku, Kyoto, Japan, Rakuwakai Otowa Hospital, Yamashina-ku, Kyoto, Japan
Objective:
To evaluate the incidence and risk factors of falls in Japanese acute care wards.
Method:
A prospective cohort study was conducted on acute care wards: medical ward, surgical ward and intensive care unit (ICU);
with 428 beds in a general hospital in Japan. All patients admitted to the wards from February 2006 to March 2008 were
enrolled and followed until discharge.
We collected the information of age, gender, and 30 potential risk factors for falling. These potential risk factors were
evaluated by a nurse within 24 hours of admission to the ward. Length of hospital stay, occurrence of falls, and length of
stay until fall were also assessed until discharge. If falls were detected, we assessed whether injuries occurred, and if
they did, we noted the severity and part of the body injured.
The incidence rate of falls was assessed by Log-rank test. Cox proportional hazard models were used to determine
univariate associations between potential risk factors and length of hospital stay until the first fall. All risk factors with pvalue less than 0.05 in univariate models were then included in a multivariate Cox proportional hazard model. Distribution
of incidence was calculated by dividing number of falls in each week of hospital stay by the number of cohort at the first
day of week.
Results:
We enrolled 21032 patients with a mean age of 66 years, and median length of stay was 7 days. During the study period,
705 falls occurred in 585 (2.8%) patients. The incidence of falls was 2.25 per 1000 patient-days, and medical ward,
surgical ward and ICU were 2.4, 2.1 and 0.3 per 1000patient-days.
Univariate analyses using Cox proportional hazard models showed 16 factors to be significant risk factors for fall (age,
history of falls, hearing impairment, muscle weakness, wheelchair use, walking aids use, mobility assistance, loss of
balance, bedridden, cognitive dysfunction, frequent urination, toileting assistance, nocturia, narcotics use, sedatives use
and psychotropics use). Using these 16 variables in the multivariate Cox proportional hazard model, we identified the
following 8 factors as independent risk factors for fall: age (≥70 years, HR 1.3; 95%CI: 1.1-1.6), history of falls (HR: 1.5;
95%CI: 1.2-1.8), loss of balance (HR: 1.7; 95%CI: 1.4-2.0), bedridden (HR: 0.5; 95%CI: 0.4-0.7), cognitive dysfunction
(HR: 1.5; 95%CI: 1.3-1.9), requirement for toileting assistance (HR: 1.4; 95%CI: 1.1-1.7), nocturia (HR: 1.0; 95%CI: 0.81.3), use of narcotics (HR: 2.3; 95%CI: 1.3-3.7), and use of sedatives (HR: 1.6; 95%CI: 1.3-2.0).
Distribution of falls in each week was from 0.6 to 1.7%. No significant difference was found between each week of
hospital stay.
Among patients who fell during the study period, 175(25%) led to minor injuries or worse. Falls were responsible for 110
head injuries.
Conclusions:
We showed that nearly 3 in 100 patients fell during their hospital stay in acute care setting. Independent risk factors for
falls on acute care wards included narcotics and sedatives use. These factors were different from those in long-term care
setting. Effective measurement against fall should be considered for those with risk factors in acute care wards.
0214
A Collaborative Pediatric Cardiac Critical Care Team Model is Associated with Improved Outcomes in Children
Following Surgery for Congenital Cardiac Defects
Alexandre Rotta, Marcus Schamberger, Lee Tosi, Shekhar Raj
Riley Hospital for Children at Indiana University, Indianapolis, IN, USA
Objective:
Previous studies suggest a strong association between intensive care unit organizational models and outcomes in
critically ill adult patients (1,2). However, very little is known about whether or not the structure of a team caring for
children and young adults following surgery for congenital heart defects affects outcomes. We hypothesized that a
collaborative, intensivist-directed, dedicated multi-disciplinary Pediatric Cardiac Critical Care team model would be
associated with improved outcomes following cardiac surgery.
Methods:
On January 1, 2009, care at our institution, a high volume, high complexity regional cardiac referral center, transitioned
from a surgeon-led team with physician extenders and on-demand multispecialty support to a collaborative, intensivistdirected, dedicated multidisciplinary Pediatric Cardiac Critical Care team model. To evaluate the effect of two intensive
care unit organizational care models, we retrospectively reviewed outcome data from patients who required critical care
following cardiac surgery from January 2006 to December 2008 (previous care model) and for 2009 (new care model).
Continuous data were analysed via t-test or the Mann-Whitney Rank Sum test. Categorical data were analysed via risk
ratios (RR) with corresponding 95% confidence intervals (CI). Values are described as means ± standard deviations,
unless otherwise noted.
Results:
All cases admitted to the Pediatric Cardiac Critical Care Unit during the study period were included in the data analysis.
The number of cases admitted per year was similar between the 2006-2008 and 2009 cohorts (331 vs. 318 cases,
respectively). Despite a higher severity of illness (3.28 ± 0.8 vs. 2.83 ± 0.98, p <0.001) and similar RACHS-1 scores (2.72
vs 2.79, non-significant) the new care model was associated with a decreased 30-day mortality (0.94% vs 2.46%, RR
0.984, 95%CI: 0.96-0.99, p= 0.07) and decreased hospital mortality (0.94% vs 4.29%, RR 0.81, 95%CI: 0.77-0.92, p=
0.004), shorter duration of mechanical ventilation (5 [2-10] days vs. 6 [2-14] days [data are medians and 25-75th%ile], p=
0.023) and a trend in reduced ICU length of stay (6.6 ± 12 days vs 8.92 ± 18 days, p= 0.12) compared to the previous
care model, respectively. An analysis of the variable direct cost showed a substantial reduction in cost per patient under
the new care model, compared to the previous care model ($US 33,435.00 vs US$ 37,282.00, respectively), resulting in a
total variable direct cost reduction of US$ 1,223,346.00 for 2009 compared to the pre-intervention period.
Conclusions:
Our data suggest that a collaborative, intensivist-directed, dedicated multi-disciplinary Pediatric Cardiac Critical Care team
model is associated with decreased mortality, decreased variable direct cost and decreased duration of mechanical
ventilation in children and young adults who require critical care following cardiac surgery. These data validate the
impression that a collaborative organizational model is associated with improved outcomes following pediatric cardiac
surgery.
References:
1. Treggiari MM, Martin DP, Yanez DN. Effect of Intensive Care Unit Organizational Model and Structure on Outcomes in
Patients with Acute Lung Injury. Am J Respir Crit Care Med 2007;176:685-690.
2. Lettieri CJ, Shah AA, Greenburg DL. An intensivist-directed intensive care unit improves clinical outcomes in a combat
zone. Crit Care Med 2009;37:1256-1260
0216
Preliminary results of a program for patients with severe mood disorders, schizophrenia or delusional disorders
on healthcare services utilization
Alessandra Coelho de Oliveira, Fernando Martín Biscione, Mônica Silva Monteiro de Castro, Fábio Leite Gastal
Unimed Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
Objective: to compare the utilization of healthcare services nine months before and after the implementation of a
program for beneficiaries of a Brazilian healthcare plan diagnosed with severe mood disorders, schizophrenia or
delusional disorders.
Methods: our institution, Unimed Belo Horizonte, is a medical cooperative healthcare plan with almost 1 million clients
residing mainly in the Belo Horizonte metropolitan area. Belo Horizonte is the capital city of Minas Gerais state, southeastern Brazil. In November 2009, our institution launched a mental a mental health program for clients diagnosed with
severe mood disorders, schizophrenia or delusional disorders. This program was designed by psychiatrists of our own
cooperative with large experience in the management of patients with these mental disorders. Before the launching, the
objectives of the program were disclosed and widely discussed with all psychiatrists of our cooperative. The program
sought to create positive incentives that would help to: a) strengthen the figure of the psychiatrist as the reference
physician for the patient; b) stress the need to care patients as outpatients; and c) address the health of psychiatric
patients as an integrated care process, by encouraging the psychiatrists to refer the patient to primary care specialties
(i.e., internal medicine, gynecology, pediatrics and geriatrics) as needed. All psychiatrists of our cooperative were invited
to participate in the program. For participation, psychiatrists had to register their patients with severe mood disorders,
schizophrenia or delusional disorders in an electronic web-based system. Physicians received a fee for the inscription of
the client and extra fees (33% more than usual fees) for each outpatient office visit of their registered patients. The
program also allowed a more frequent follow-up during eventual exacerbation periods (up to ten visits in 60 days, twice a
year) than is allowed by the medical cooperative for non-participant patients. To measure the impact of the program on
healthcare utilization, we compared the rates of outpatient office visits with psychologist, hospitalizations due to
psychiatric causes and emergency care visits nine months before and after the inclusion of the patient in the program.
Person-time was used in the denominator of these rates. Hospitalizations due to psychiatric causes were defined as those
characterized by a code belonging to Chapter V (Mental and behavioural disorders) of the International Statistical
th
Classification of Diseases and Related Health Problems 10 Revision.
Results: From November 2009 to July 2010, 1161 patients were included in the program (953 with severe mood
disorders and 208 with schizophrenia/delusional disorders); 34 out of a total of 117 psychiatrists were responsible for the
inscription of these patients. Women predominated in the mood disorders group (70%), while no difference was observed
in gender distribution for schizophrenia/delusional disorders group. After nine month of implementation of the program,
outpatient physician visits increased 15%. Hospital admissions reduced from a mean of 12.4/1000 patients-month before
the program to 7.9/1000 patients-month after the program, representing a decrease of about 35.8%. A 30.8% reduction in
the rate of emergency care visits was also observed, from 179.6/1000 patients-month before the program to 124.3/1000
patients-month after the program. Finally, a 6.9% decrease in the rate of outpatient visits with psychologist was also noted,
from 20/1000 patients-month before the program to 18.6/1000 patients-month after the program.
Conclusions: nine month after the implementation of the mental health program, we observed a decrease in
hospitalizations, emergency care visits and outpatient visits with psychologist, and an increase in outpatient physician
visits. Although the time of follow-up is too short to draw definite conclusions, this study seems to enforce the importance
of designing adequate policies in order to avoid inefficient and fragmented psychiatric care. Further evaluation of this
program is warranted.
0217
Managing the performance of senior doctors: building engagement through an integrated, clinically based
credentialling process.
Grant Phelps, Sarah Harper
Department of Health, Victoria, Australia
Objective
To enhance the engagement of senior medical staff through the use of robust credentialling and performance
development and support processes.
Methods
In 2007, the Victorian Department of Health (the department) implemented a statewide Credentialling and defining scope
of clinical practice policy for senior medical staff in public hospitals, in an effort to support clinical practice and enhance
clinical engagement. Victorian public hospitals have independent governance responsibilities, with departmental policy
providing principle based guidance on the management of senior medical staff. The policy requires all senior medical staff
to undergo a formal re-credentialling process involving an assessment of clinical practice every three to five years (the
credentialling cycle)
To support the credentialling cycle, the department has sought to develop a performance development framework
recognising that maximising engagement with and by senior medical staff is a critical precursor to high performance
health care. The use of formal performance management processes for senior medical staff is poorly developed in
Australian health care settings.
A literature review and in depth interviews were undertaken to develop a performance framework for senior doctors in
Victorian public hospitals. An expert advisory group provided guidance and statewide forums facilitated stakeholder input.
Results
Partnering for performance - a performance development and support process providing a suite of processes and tools to
support, recognise, reward and enhance senior doctor performance was introduced. The framework supports ongoing
formal and informal communication about clinical care to ensure organisations and senior doctors share a commitment to
high quality patient care. It establishes a context for two-way feedback and goal setting.
Additional benefits for participants include assisting them to meet their Continuing Professional Development
requirements and identifying opportunities for career progression. Over 200 medical directors and department/unit heads
have attended training sessions to assist in local implementation of Partnering for performance. This includes
representatives from 100% of metropolitan health services and 69% of rural health services.
Conclusions
A performance development framework that emphasises an organisational focus on patient care and encourages clinician
input has considerable potential to drive clinical engagement and to achieve individual and system level improvement.
0219
A prospective cohort study on factors influencing the development of pressure ulcers in Hong Kong Private
Nursing Homes
1
2
2
3
Gloria Halima Aboo , Samantha MC Pang , Enid WY Kwong , Bernard MH Kong
1
Pamela Youde Nethersole Eastern Hospital, Hong Kong East Cluster, Hospital Authority, Hong Kong, China
2
Hong Kong Polytechnic University, Hong Kong, China
3
Hong Kong East Cluster, Hospital Authority, Hong Kong, China
Objective: To study the incidence of pressure ulcers and to identify the factors that influence pressure ulcer development
in private nursing homes in Hong Kong.
Methods: After obtaining informed consent, a was a prospective cohort study was conducted for 28 days among a
sample of private nursing homes in Chai Wan under the care of Community Geriatric Assessment Team (CGAT) of the
Hong Kong East Cluster (HKEC). Before data collection, HKEC wound nurse trained fourteen nursing students as
assessors in pressure ulcer identification and established the inter-rater reliability (Kappa > 80%, ICC=0.76) on the scales
use for data collection, including the Personal Characteristics Form (PCF), the Cumulative Illness Rating Scale (CIRS),
Bedford Alzheimer Nursing Severity Subscale (BANS-S), Personal Daily Life Activities Scale (P-ADL), Modified Braden
Scale (MBS), Skin Assessment Chart (SAC) and the Resident Observation Sheet (ROS). Assessors commenced by
assessing the residents’ pressure ulcer risks, and presence of existing pressure ulcers, following which residents were
assessed every two days within the study period. A final assessment was conducted and cases were closed when (1) no
pressure ulcers developed after 28 days of observation or (2) the residents left the homes temporarily (eg hospitalization)
or permanently (eg death) within 28 days. Bi-variate analyses (chi-square and the independent t-test) were used to test
the differences of the residents-related factors between the residents who had and had not developed pressure ulcers.
Logistic regression was further used to identify the patient-related factors for pressure ulcer development, while inductive
content analysis of resident observations was used to identify the care- and environment-related factors.
Results: From February to July 2007, 368 residents (mean age 81, range = 39 to 100, SD = 9.59) in four private nursing
homes were recruited. Prevalence and incidence of pressure ulcer were 7.6% and 28% respectively. Of 28 residents who
had pre-existing pressure ulcer, 21 (75%) developed new ulcers, and 82 (24.1%) residents developed their first pressure
ulcers within 28 days. The commonest pressure ulcer sites were coccyx; mid-vertebrae, sacrum, and majority were in
stage I or II. Factors for pressure ulcer development included (1) Resident-related: require feeding by others (OR=0.7, CI
95% 0.01–0.4, P<0.02), on tube feeding (OR=0.1, CI 95% 0.02–0.6, P<0.01), poor activity (bedbound/chairbound)
(OR=0.4, CI 95% 0.2–0.6, P<0.001), poorer activities of daily living (OR=0.9, CI 95% 0.8–1.0, P<0.06), cognitive
impairment (OR=0.8, CI 95% 0.7–0.9, P<0.006), impairment induced by neurological or psychiatric disease (OR=1.3, CI
95% 1.0–1.6, P<0.05). (2) Nursing home-related: low nurse-resident ratio, and higher proportion of basic nursing care
delivered by semi-skilled workers (OR=0.007, CI 95% 0–0.6, P<0.001); (3) Care-related factors: lack of an active skin
care program, insufficient assistance in mobilization and activity, lack of/inappropriate use of pressure re-distribution
devices; and (4) environmental factors: limited space in home, high temperature/humidity and poor ventilation.
Conclusion: This study confirmed that occurrence of pressure ulcer is a major problem in private nursing homes.
Shortened hospital stay to save healthcare costs lead to earlier discharge of patients who require assistive care in longterm care settings. Private nursing homes have to accommodate residents at severe levels of infirmity and with greater
dependency. However, pressure ulcer management in private nursing homes can be improved by early prediction of the
risk factors found in this study. They can inform the homes to implement the most effective preventive measures including
turning and skin care (with no/marginal additional costs), on-site nurse to supervise semi-skilled workers, and staff training
and education by community nurses from hospitals. The resulting improvement in pressure ulcer management will lead to
improve quality of life and reduce hospitalisation needs residents.
0221
Solifenacin or Tolterodine, which one is better for treatment of overactive bladder syndrome in Chinese Women?
Ralph, C.W. TUNG, Cecilia CHEON, Anny TONG
Queen Elizabeth Hospital, Hospital Authority, Hong Kong
Objective:
To determine the treatment efficacy, quality of life improvements and side effect profiles between Solifenacin and
Tolterodine in treatment of overactive bladder syndrome (OAB) in Chinese Women.
Methods:
This trial was designed as a prospective double blinded two-arm, randomized controlled trial for comparing symptoms and
quality of life improvement between 2mg Tolterodine BD and 5mg Solifenacin daily in OAB patients.
Patient with diagnosis of overactive bladder syndrome were recruited from Urogynaecology Clinic, Queen Elizabeth
Hospital from year 2008 to 2010.
For patients newly diagnosed to have overactive bladder syndrome, the treatment will be started immediately after
recruitment. Candidates who were already on treatment for OAB, their original regime were be stopped for 2 weeks as
watch-out period before further proceeding to randomization and start the trial according to the protocol. All candidates
were required to sign a written consent form after detail explanation of the study programme.
Candidates were randomized into 2 groups by computer for taking either Tolterodine 2mg twice daily of Solifenacin 5mg
daily and placebo. Both candidates and investigators were double blinded during the randomization process.
The women are advised to take the medication accordingly for 12 weeks in total. Follow-up visits were arranged on week
4 and week 12 post treatment and tools including symptom score, urgency perception scale, Visual analogue scales IIQ 7,
UDI 6, Kings Health Questionnaires were used for assessment of treatment efficacy and effects of improvement on quality
of life.
Results:
There were total 143 patients were recruited and 71 patients were randomized into Tolterodine group and 72 patients
were randomized into Solifenacin group. Finally there were 118 patients completed the study.
There were no significant difference for baseline demographic data, OAB symptoms score and VAS, Mean warning time
among 2 groups of candidates.
For post-treatment results, there was statistically significant difference in reduction of UPS in Solifenacin group (mean
reduction of UPS in S = -0.853 vs T = -0.526 , p=0.043) for urgency symptom. For symptom score of micturition frequency,
Solifenacin group shows better improvement than Tolterodine group but not reach to level of statistically significance.
(Mean reduction in symptom score of S = -1.72 vs T = -1.25, p= 0.053). For mean warning time and VAS, it again shows
better improvement in Solifenacin group but not statistically significant when compare with Tolterodine group. (mean
warning time improvement S = 14.225 vs T = 15.360 (p = 0.804), VAS S = -3.08 vs T = -2.55 (p=0.115)).
For quality of life improvement, King’s Health Questionnaire (KHQ), IIQ 7 and UDI 6 short form questionnaire were used
for assessment. There were significant better improvement in Solifenacin group when compared with Tolterodine group in
Domain of Incontinence Impact (p=0.025) , Role Limitation (p= 0.004) and Social Limitation (p=0.004). There were also
better improvement in other major domains in KHQ but they did not reach statistical significance. When short form of
questionnaires including IIQ 7 and UDI 6 were used, it showed the significant better improvement in Solifenacin group
when compared with Tolterodine group. (UDI 6 – S = -16.284 vs T = -8.292, p = 0.012, IIQ 7 – S = -21.678 vs T = -6.227,
p = 0.007)
Conclusion:
With 12 weeks treatment 5mg Solifenacin daily shows statistically better improvement in improving quality of life of OAB
patients when compare with 2mg Tolterodine BD. For symptoms of OAB, it showed there is significant improvement in
urgency symptom of patient taking Solifenacin. For a single dose regime and better improvement of quality of life, it
suggested that Solifenacin is the better agent then Tolterodine for treatment of Overactive bladder syndrome in Chinese
women.
0223
Redesigning the ICU Nursing Discharge Process; A Time Series Study using Statistical Process Control to
Demonstrate Process Improvement
1
1
2
Wendy Chaboyer , Frances Lin , Michelle Foster
1
2
Griffith University, Gold Coast/ Queensland, Australia, Gold Coast Hospital, Gold Coast/ Queensland, Australia
Objective: The purpose of this study was to evaluate the impact of a redesigned intensive care unit (ICU) nursing
discharge process on ICU discharge delay, hospital mortality and ICU readmission within 72 hours.
Methods: A time series study using statistical process control analysis was conducted in one Australian general ICU.
The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured 15
months prior to and 12 months after the redesigned process was implemented. After approval from a university’s and
hospital ethic’s committee, medical, nursing and other healthcare staff were told about the study and signed consent
forms. Patient consent was waived by the ethics committees. Observations and interviews were used to understand the
current discharge process to determine its redesign. The redesign process included: 1) appointing a change agent to
facilitate process improvement; 2) developing a patient handover sheet; 3) requesting ward staff to nominate an estimated
transfer time; and 4) designing a daily ICU discharge alert sheet that included an expected date of discharge.
Results: A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12
months after the implementation of the new discharge processes. The P-chart showed there was no difference in
hospital mortality and the U-chart showed no difference in ICU readmission within 72 hours during the study period.
However, process improvement was demonstrated in the XmR chart by a reduction in the average patient discharge
delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention).
Conclusions: This study demonstrated that a structured redesign process improved the efficiency of the ICU discharge,
without compromising patient safety. Involving both ward and ICU staff in the redesign process may have contributed to a
shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use
of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed
the new process into practice.
0227
Feasibility, acceptability and utility of an e-cardiovascular risk platform amongst physicians and patients in the
primary care setting.
1
1
2
1
Janice M Johnston , Tuan M Vu , James HB Kong , Helen Tinsley
1
2
School of Public Health, Department of Community Medicine, The University of Hong Kong, Hong Kong, Central
3
Medical Practice, Hong Kong, Department of Health, The Government of the HKSAR, Hong Kong
Background: Cardiovascular disease (CVD) is the leading cause of death in Hong Kong accounting for 16% of all deaths
for those aged 45 years and over in 2007. Computerized clinical decision support systems (CDSS) assist health
professionals to make evidence-based decisions and provide case-specific advice. It’s usefulness as prevention and risk
reduction strategy for patients with diabetes, hypertension among others, especially in primary care has been clearly
demonstrated. Individually tailored CVD risk reduction (CVDRR) decision support tools delivered through hand-held
devices (e-platform on mobile phone) may improve provider planning for and patient involvement with CVDRR strategies.
This pilot study aims to assess provider and patient attitudes towards, as well as the feasibility, utility, and acceptability of
e-platform technologies via a mobile phone for CVDRR in primary care.
Methods: Patients were recruited from a private general practitioner (GP) in solo practice, a specialist in group practice
and a GP in the Yau Ma Tei Jockey Club Polyclinic. The inclusion criteria included patients aged 45-79 years who used a
JAVA enabled and internet accessible mobile phone. General health information (GHI) (weight, height, blood pressure,
smoking status) and cardiovascular risk profile (CVDRP) (cholesterol profile, HbA1c) were recorded at baseline and 1month follow-up, respectively. Cardiovascular risk scores using Framingham Cardiac Risk Score algorithm were
calculated according to individual GHI and CVDRP. The risk score, advice on health behaviour modification was uploaded
via a secured server to one-time password secured software installed on the patient’s mobile phone. Primary outcome
measurement: clinical change at the 3-month follow up as compared to baseline. Secondary outcomes: Provider and
patient self-perceived usefulness, feasibility and acceptability as assessed by pre-post questionnaires [with 5-point Likert
scales (1 -> 5: represents ascendant degree of agreement)]. Providers and patients participated in three post intervention
focus groups. Descriptive-analytical statistical methods were used. Grounded theory guided the qualitative data analysis.
Results: 20 patients participated in the study. Patient’s mean age was 52 years, 53% were male. 85% had secondary or
lower education, and 95% did not smoke. Patients gave high score to the statements “Doctors explained carefully what is
happening to my health” [mean score (M)=4.05, standard deviation (SD)=0.70], “I understand my doctors’ advice”
[M=4.00, SD=1.00], and “I remember my doctors’ advice” [M=4.37, SD=1.01], pre-intervention. However, patients were
less likely to understand their doctors hand writing [M=3.58, SD=1.07]; and were uncertain about heredity, stress and
high-cholesterol as CVD risk factors [M=3.05, SD=1.58; M=2.32, SD=1.20 and M=2.21, SD=1.47, respectively]. While
patients perceived the e-platforms for personal decision support (average score for all items > 4.5) to be useful, and
acceptable, they were worried about their cardiovascular health status [M=3.58, SD=1.35] as the intervention CVD
information confusing (Preliminary results at one month follow up). Post-intervention patients reported sharing their
personal health information with their health care provider, and were willing to continue using the service if available.
Conclusions: This pilot study has provided preliminary evidence of the feasibility, acceptability, and utility of an eplatform in primary interventions for CVD. Further research should focus on developing appropriate measures to enhance
primary intervention strategies, especially for patients with chronic diseases.
0228
Combating MRSA Infection through Safety & Quality Management on Environmental Cleansing Program
Wing Kee Patrick SIU, Pui Yee Edith WONG
Queen Elizabeth Hospital, Hong Kong
Objective
In our hospital, our department is ranked the third highest of Methicillin-resistant Staphylococcus aureus (MRSA)
prevalence rate which increases morbidity, length of stay, mortality and cost - that is why we have to combat cross
infection of MRSA by a structured environmental cleansing program to ensure safety and quality of clinical service.
Method
The department has initiated a safety and quality management by a structured environmental cleansing program. The
formulation of this structured cleansing program is based on the previous research result. A new cleansing protocol was
introduced, and staff compliance and environmental cleanliness were audited periodically.
Result
The environmental cleansing compliance rate improved significantly from 75% to 100% within 3 months. The cleanliness
audit score ranged from 3.7 to 4.3 out of 5. There was no significant change on MRSA infection rate compared with
previous result. No observable correlation was found between environmental cleansing compliance and cleanliness audit
as well as MRSA infection rate. However, it increased staff awareness on importance of infection control.
Conclusion
Environmental cleanliness had an important safety and quality role to play in controlling the prevalence of MRSA infection.
It was not the only variable that affected infection control. However, when combined with good hand hygiene practice, the
cleansing program would synergistically reduce MRSA infection rate. The current environmental cleansing program was
audited only by visual assessment. Therefore, we plan to conduct a scientific research to verify effectiveness of cleansing
routine underpinning safety and quality of clinical service against MRSA infection.
0229
Application of a surgical ward nursing care and information systems effectiveness of the quality of the process.
WANG WEI NA, CHANG Kuei Luan, WANG WI-NA
Chi-Mei Medical Center, Tainan,yung-kung, Taiwan
Purposes：To explore the application of surgical ward nurses of the nursing process, nursing information system
operation conditions, factors and strategies to improve satisfaction and lack of practice.
Method：This study literature analysis, questionnaires, interviews and other research. The survey was conducted with a
total of 28 surgical ward nurses, a total of 10 interviews with nurses at all levels. The questionnaire survey data was
transferred to Excel statistical software for analysis.
Results：First, the actual operation of the nursing process, nursing situations: the nursing process and the lack of
specific, feasible, individual and is too simplified, and by the quality control audit found that 66% of the full rate. Second,
the quality of nursing process factors and influence strategy: Nursing audit team leader for the lack of consensus on the
nursing process, care and a lack of specialist nursing information system problems. Third, the actual operation of the
nursing process, nursing staff satisfaction: The majority of nurses believe that the efficiency of care and information
technology is at a "satisfactory" level, then the process of writing the quality of care are at a "not yet satisfactory" level.
Fourth, the lack of nursing staff during the implementation and improvement of nursing practice areas:
1. Lacks the necessary expertise to the nursing process, disease specialist ward should be established to formulate a
common disease ward nursing process model, and holding in-service education, 3. Design the nursing process, the
nuclear form of quality control inspection, audit notice from the nursing team leader on a regular basis, but also at the
ward meeting for the audit results and discuss the lack of public awareness projects.
Conclusion：Nursing information system effectively enhanced the efficiency of written records of the nursing process,
however, was limited due to the lack of professional nursing care process, writing knowledge and strict quality control. To
the nursing process, the quality of the writing of poor performance, it is proposed to promote use of continuous quality
method to provide patients with a complete nursing process for future nursing information system to improve the quality of
nursing process reference.
0230
Development of An Exceptional Apple Culture
Tong Huey Goh, Ai Ling Teo
Tan Tock Seng Hospital, Singapore
Background:
Since 2005, our Hospital has been ranked fifth or sixth in service standards among the six Singapore government
Hospitals in the annual Ministry of Health Customer Satisfaction Survey (MOH CSS). This perennial ranking will affect
society’s confidence in our Hospital as well as staff morale. Management therefore took on a project to establish a
hospital-wide service framework and culture which the lack-of had been identified as the causes of the lack luster
performance.
Objective:
The Project aims to inculcate a strong and consistent patient-centred service culture across our Hospital by measuring
and improving our service performance.
Methods:

Build Foundation (Jan- Apr 09): A Quality Service Management Taskforce led by the Chief Operating Officer was set
up. Leaders from various service units analysed survey data and determined that Care, Empathy and
Professionalism (CEP) are service values which will improve patient satisfaction. A set of ten service behaviours that
exhibit the CEP values were also confirmed.

Build Framework: A service framework - "The Apple Philosophy", was built on the PDCA cycle.
TTSH Apple Philosophy Framework
Measure
Learning &
Celebrate
Achieve-
Healthy
&
Satisfied
Patients
ments
Communication
Visualise
Achievet
Drill
Down
Improve
Services
The framework is named as such because the fruit symbolises health and satisfaction that our Hospital wants
patients to return home with. A motivating tagline – “be exCEPtional”, was also coined.

Framework in Action (May 09 – current):
•
Learning: The Training Department conducts service focused “Apple Induction” for new staff and “Apple
Intermediate” for existing staff. Individual departments also conduct service focused roll calls.
•
Communication Activities: The Taskforce members participate in departments’ meetings to introduce and
refresh the CEP values; Hospital-wide road shows to reinforce the importance of service quality through poster
exhibitions and related games; Service Behaviour Cards to constantly remind all staff to exhibit CEP in their
work.
•
Measure, Drill Down & Improve: Surveys and focus groups are conducted three times a year. The results
are used to improve the identified service shortfalls.
•
Visualise: Our Hospital visualises our service commitment and achievements through – a Service Quality
Commitment Mural; Posters, Service Achievement Walls in each Outpatient clinic; Email communications.
•
Celebrate Achievements: Friendly inter-department service related competitions; A carnival style celebratory
event at the end of the year.
This framework in currently on its third cycle since 2009.
Results:
The “Overall Satisfaction Score” (percentage of patients who rate their overall satisfaction with our Hospital’s services
“Good” or “Excellent") have increased:
Overall Satisfaction Scores 2009 – 2010
Survey 1
Survey 2
Survey 3
Net Improvement
2009
63.7
68.2
70.3
6.6
2010
65.3
71.1
78.1
12.8
Our Hospital had also leapt to the second position in the 2010 MOH CSS.
Conclusions:
This framework has improved our Hospital’s service performance since its inception in 2009. From the results above, it
has proven to be an effective guide to improve our Hospital’s service standards in a systematic and measurable way.
This project has helped to understand what drives patients’ satisfaction and staffs’ commitment to provide quality service.
As a result, patients are now more satisfied with our services and staff are more motivated to put forth their best. Service
has now “come from everyone’s hearts”.
0231
Extra healthcare costs associated with antimicrobial prophylaxis in colorectal surgery by using profiling data at a
university hospital in Japan
Narue Nakabayashi, Masahiro Hirose
Shimane University Hospital, Izumo, Shimane, Japan
Objective: As postoperative infections might bring about an expansion of length of hospital stay (LOS) and extra medical
costs, this study aims to explore the relationship between antimicrobial prophylaxis (AMP) and health care costs from the
viewpoint of hospital administration.
Methods: We obtained data from 220 surgical patients with malignancies in the colon and rectum admitted between
2007 and 2009 after excluding patients that were treated with chemotherapy. Next, we classified the patients according to
case and control groups, based on infection status: patients belonging to the former were identified as those that were
treated with antimicrobial prophylactic utilization for durations beginning on the day of surgery until after the fourth
postoperative day and/or those that were re-administered with antimicrobials once again after the initial antimicrobial
prophylaxis due to postoperative infections. Patients in the control groups were those that were given antimicrobial
prophylaxis from the day of surgery until the third postoperative day. After employing these identification criteria, there
were 49 control patients and 112 case patients. We analyzed the following variables of both groups: hospitalization
charge, AMP agent use during hospital stay (drug name and administration period), length of hospital stay (LOS) by using
administrative profiling data. Furthermore, in order to explore factors associated with the case group we analyzed patient
age, patient gender, comorbidities (hypertension, diabetes, hyperlipidemia), operative duration, wound-class that shows
clean/contaminated surgery, ASA-PS that shows preoperative condition of patient, and with or without ileus by utilization
of medical chart. Statistical significance was set at 0.05.
Results: Most patients from both groups were appropriately given AMP agents (second-generation cefem or oxacefem)
consistent with the guidelines of infection-related associations. The LOS of the control group (24.6 ± 12.1 days: mean ±
SD) was shorter than that of the case (49.4 ± 35.2 days) (p<0.05). We found that: there was no significant difference in
preoperative LOS (control group =7.7 ± 7.4 days vs. case group = 8.9 ± 9.4 days, p=0.44). However, we observed a
significant difference in the case of postoperative LOS (control group = 15.9 ± 7.3 days vs. case group =39.6 ± 34.1 days,
p<0.05).
Hospitalization charge of the control group (15130 ± 3930 USD) was lower than that of the case (23130 ± 1212 USD)
(p<0.05), but hospitalization charge per day of the control group (670 ± 160 USD) was higher than that of the case (530 ±
130 USD) (p<0.05). In order to explore the difference in hospitalization charges between the control and case groups,
medical charges were calculated by clinical practical services. The following charges were observed: Surgery/operation
charges [control group: 7660 ± 1700 USD, 55% of hospitalization charge (13860 USD); case group: 8600 ± 3020 USD,
40% of hospitalization charges (21440 USD)] was the highest in the both groups. Admission charge of the case group
(8210 ± 5820 USD, 38.1%) was higher than that of the control group (4420 ± 1910 USD, 31.7%), as LOS of the case
group (49.4 ± 35.2 days) was longer than that of the control group (15.9 ± 7.3 days).
With regard to factors associated with the case group, significant factors are wound class (Odds ratio: 7.53, p=0.01) and
presence of hypertension (OR: 2.89, p=0.02).
Conclusions: AMP agents in our hospital were found to generally given according to the recommended guidelines. It
cloud be thought that medical resources are given to postoperative infections different from the primary diseases,
Hospitalization charge is significantly higher than that of the control group due to long LOS of the case group, it is
important for the hospital administrators to quantify the additional costs on top of the primary diagnosis in order to properly
deal with infection control and hospital management.
0232
Project of Improving the rejected Rate of Specimens in a Neurological Ward
Nai-Tan Chang, Ching-Ching Cheng, Tzu- Chi Kuan
Chang Gung Memorial Hospital, Taoyuan Hsien, Taiwan
Objective:
Neurological patient often needs a series of laboratory examination to confirm the cause of disease and further disposal of
treatment. Therefore, the specimen collection and delivery is an important nursing activity, and it is also relevant not only
the quality of health care but also the patient satisfaction. Any steps of error in the collection procedure will increase staffs’
work-loading, waste of health care, and more seriously it will affect the recovery of patient and extend the length of
hospital stay. The purpose of this project was to decrease the rejected rate of specimens, reduce the workload of staff
and waste of health care by improving the fluent of work flow and enhancing the nurses’ knowledge level and skill about
specimen collection. It hopes to improve the patient satisfaction and ensure patient safety.
Methods:
A improve project team was emerged. The chart audit, quiz of specimens’ collection procedure, questionnaires, and site
observation using structured- checklist was used to collect the data about the knowledge and behaviour among nurses in
a neurological ward at a medical centre in January 2010. The causes of specimen-rejected were also collected and
analyzed.
After coordination and communication with other relevant departments, the strategies were applied to avoid the individual
mistake and handwriting. We purchase barcode printers and readers, establish specimen barcode information technology,
add notes of special specimen in checklist and amend the double-checking procedure; we also enhance the ability of
specimen collection of staff by marking the order of each specimen collection, improving the blood sampling equipment,
arranging the space of specimen boxes, strengthening and enhancing the in-service training courses.
Results:
The rejected rate of specimen was 1.21% from January 2009 to December 2009. There were three issues related to the
high rejected rate:(1) the quiz test revealed the correction score was only 65%. It indicated that the knowledge of
specimen collection was poor among nurses. (2)The double-checking procedure before specimen submission did not
perform fulfilled. (3)The blood sampling equipments was not suitable for use. After implementation of this project, results
had showed that the knowledge level of blood specimen collection was improved from 65% to 93.9% and the rejected rate
of specimen had decreased from 1.21% to 0.69% from January 2010 to December 2010.
Conclusions:
Laboratory examination plays an important role in clinical medicine. Higher rejected rate of specimen will cause the
conflicts and argues between different departments easily. Specimen collection and delivery is also relevant to clinical
care quality and patient satisfaction.
This project established a specimen barcode information technology, improved the blood sampling equipment and holding
in-service training courses to deal with the high rate of specimen-returned. The results indicted that this project was well
to promote the level of knowledge and skill of blood sample collection among nursing staffs and decreased the rejected
rate of the blood specimen effectively.
0233
Improving hospital environment through LEAN and GREEN.
Benedict Fu
Pok Oi Hospital, Hospital Authority, Hong Kong, China
Background:
After the monthly generator test, the Variable Air Volume (VAV) device for controlling the air-conditioning (A/C) would be
automatically reset to 15℃. Staff needs to walk through the department for readjusting the room temperature manually.
However, some units may forget to exercise this and lead to undesirable working environment and energy wastage.
Problem Statement:
Motion wastage of staff was identified during the temperature readjustment exercise.
Objectives:
By using the concept of GEMBA WALK and Automation, elimination on motion and energy wastage are expected.
Methods:
1. Green Ambassador Visits – Department of Radiology was the pilot location visited
2. Time schedule of VAV controller - To assign different temperature settings during office hour and non-office hour
3. By-pass of VAV controller - To fix temperature for common areas through Central Control Monitoring System
(CCMS)
4. Suspension of A/C Supply during non-office hour
Results:
1. Projected annually 11,412 footsteps, 168,985.68 kWh (CO2 emission reduced 118.29 tonnes) and $135,188.54
saved in DR.
2. Extending the project to other departments
3. De-lamping and other energy saving opportunities
4. $194,309.91 saved in total after extension of the “Green POH” program to other departments
Conclusions:
A comfortable environment for patients, staff and visitors was achieved through the implementation of the project. Energy
and money was saved and further KAIZEN initiatives for Green Purpose were evolved.
0234
Medical Clinic Accreditation Program In Malaysia: A Pilot Survey
M.A. Kadar Marikar, M.A. Hadi Mohamad Zohdi
Malaysian Society for Quality in Health (MSQH), Kuala Lumpur, Federal Territory, Malaysia
Objective:
To evaluate the applicability of MSQH newly completed Accreditation Standards on Medical Clinics.
Methods:
Since mid 2007 MSQH had developed an accreditation standards and an interpretive guide to their standards designed
specifically for General Practice Clinics. This work had been completed in 2009 and a pilot study conducted in the same
year.
Two peers from the GP practice were identified, trained and appointed: These two surveyors conducted the pilot survey in
one private establishment and one public clinic.
Results:
1. The accreditation had been well received and the Standard is very much applicable and surveyable to the clinics
surveyed. On the logistic side there is a need to re-look how to operationalize the survey.
Issues identified are as below:
1. Standard 1.1: Overlap evidence of compliance. Evidence 2 and 4 are the same.
2. Standard 2.1 : To add in additional evidence of compliance –
-
Certification by Fire Dept on safety of premise (where applicable)
3. Standard 2.4.2 : To add in additional evidence of compliance –
-
Security access for electronic medical records (EMR) (where applicable)
4. Standard 2.5 : To add in additional evidence of compliance –
-
Storage of DDA drugs in a secured location
-
List of approved signatures/initials of registered medical practitioners (including locums) for prescription
slip (where applicable)
-
List of standard drug abbreviations used
Conclusion:
1. The standards developed by MSQH were found to be suitable and applicable to this medical clinic survey for both
public and private sectors.
2. The surveyee’s response and feedback were very positive and had very little difficulties in understanding and
interpreting the standards and were delighted with the way the “peer review process” was implemented.
0236
Improvement of Home Care on Traumatic Ambulatory Surgery
Su-lan Wu
Chang Gung Memorial Hospital, Guishan Township,Township county, Taiwan
Introduction:
The needs of nursing care vary by each surgical patient. Therefore, it is necessary for nurses to provide physical,
psychological, and societal help according to their needs. The anxiety of patient increases due to time constraint in
ambulatory surgery. Proper nursing instructions and individual, whole, and continuous peri-operative nursing care can
reduce patient’s anxiety and improve patient’s motivation in learning self-care so as to reduce patient’s complications after
surgery and decrease cost. The purposes of this project for traumatic ambulatory patient are to (1) decreasing the rate of
telephone counseling after discharge from 27.2% (6 cases) to 4.5% (1 case); (2) decreasing the rate of returning to
emergency room within two days from 2.75% to 0.9%; (3) the satisfaction rate of nursing instruction above 4.5 points out
of 5 (90%).
Methods:
This project used Quality Control Circle (QCC) method for data collection and analysis as well as improvement of
problems found. The satisfaction rate of 3.1 points on nursing instruction was found. The major causes were that (1)
patients could not pay attention to nursing instructions due to high anxiety before surgery and ending up 27.2% of
telephone health consultation after discharged; (2) a readmission rate of 2.75% to emergency room within 2 days after
discharged was noted; (3) incomplete rate of 46.7% in nursing instruction sheet was due to lack of time to complete
nursing instruction and nursing record. After literature review, the resolutions were as follows: (1) taking the initiative
telephone health consultation after patients discharged to improve continuous caring; (2) establishing nursing instruction
standards for nursing staff. %. In order to improve these drawbacks, this project proceeded from February 21, 2009 to
May 30, 2009 for collective 180 samples for telephone health consultation after they were discharged. On June 1, 2009
patient satisfaction and readmission rate to emergency room were evaluated for effectiveness of the project.
Results:
In order to understand the effectiveness of the project, a comparison of cases of telephone health consultation after
discharged, readmission to emergency within two days, and satisfaction rate before and after project implemented and
they were: (1) the rate of telephone health consultation after patient discharged was from 27.2%(6 cases) to 4.5%(1 case);
(2) the rate of readmission to emergency within two days was from 2.75% to 0%; (3) the satisfaction rate was 4.9 points
out of 5.
Discussion and Conclusions:
After implementation of this project for telephone health consultation after patient discharged, there were an increase of
patient’s satisfaction and a decrease of complication after surgery for improving quality of care. This project provides
ambulatory care department a standardized nursing care instructions and telephone health consultation services to
promote continuous nursing care and quality of care. The telephone health consultation service can apply to discharge
department in the future to provide patient total continuous care from admission to discharge.
Key words: telephone consultation, ambulatory surgery patient, peri-operative nursing care.
0239
Evaluating Nursing Practice on NHHD training: Promoting patient independence
LF Ho, CMK Tang, SWY Wong, ILL Kong
Division of Nephrology, Department of Medicine & Geriatrics, Princess Margaret Hospital, Hong Kong
Introduction:
Noctural home haemodialysis (NHHD) provides an alternative home-based dialysis therapy to enable patients to continue
their work and achieve better patients’ outcomes at reduced cost. A systematic nurse-initiated patient self care training
program is provided for NHHD patients. The training outcomes were positive and participants were able to perform NHHD
safely and independently.
Objectives:
The aim of this study is to determine the effectiveness a systematic patient training program for nurse interventions in
achieving the outcome of maximum independence for patients with long term end-stage renal disease requiring
haemodialysis in home setting.
Method:
A retrospective analysis was carried out on 22 NHHD patients who received training from the period of 2006 to 2010
(Mean age: 44.3 and average training sessions: 26.8). Home and independence assessment, regular patient discussion
with mutual learning contract, home visits and multidisciplinary case meetings were conducted. A NHHD clinical pathway
was developed locally to guide the training procedures. Various teaching aids including procedure flipchart, information
booklet and video show were prepared to facilitate and standardize the training process. Each patient had to pass oral
and practical examinations on the health management, HD machine operation, safety issue and emergency handling
during HD. Feedback from patients and their family was solicited through questionnaires and interviews to evaluate their
perceptions of the effectiveness of self-care interventions and nurse’s approach in promoting individual independence.
Participants measured quality of life (QoL) based on the conceptual frameworks of Baldree haemodialysis stressor scale
(BHSS), Jaowiec coping scale (JCS) and Ferrans quality of life index (QoLI). Perceived stress, coping strategies and QoL
were scored before (pre-NHHD training) and post-12 month. Wilcoxon signed-rank test was used for statistical analysis.
Results:
All participants reported satisfaction with the nurse teaching competency, quality of training standards and logistic
arrangement of the program. 95% participants commented teaching methods and materials provided were valuable,
informative and useful, and the topics of trouble shooting and management of emergency complications were particularly
helpful. 90% reported an increased confidence in handling with NHHD independently and safely after the training. 95%
reported that self cannulation was the most difficult part of training. The patients reported ‘a great enjoyment’ of the
daytime freedom that allowed them to actively engage in full time employment and participation in normal social activities.
9 out of 22 participants started NHHD for 12 months demonstrated that training impacted positively on patients’ self care
ability and there were reduced stress, enhanced coping skills and improved QoL in patients. Post 12-month mean scores
showed significantly downward in BHSS (Z= -1.96, p=0.05) and JCS (Z= -2.37, p=0.018) and upward in QoLI (z=-1.96,
p=0.05). Limited vocational leave and uncontrol to future showed marked improvement. Coping strategies changed from
passive self acceptance to disability to objective thinking when dealing with problems after training. QoL reviewed great
improvement since the patients could return to normal employment after training and adoption of NHHD.
Conclusions:
A well-structured NHHD patient training program could strengthen patients’ self care ability and control over their chronic
disease which in turn to enhance their confidence and self esteem, patients’ perception of their overall well-being as well
as improvement in QoL. To booster confidence in self-cannulation, re-examination of patients will be conducted every half
year to enhance their cannulation skills. As the existing program has also demonstrated encouraging patient clinical
outcomes, future studies would be extended to evaluate the efficacy of the training program on relatively high-risk chronic
kidney disease’s patients.
0240
The use of multiple strategies in monitoring and improving the quality of artificial arthroplasty
Wen-E Yang, Mel S Lee, Wen-Jer Chen, Chiu-Tsu Lin
1
2
Chang Gung Memorial Hospital, Keishan, Taoyuan, Taiwan, Chang Gung University College of Medicine, Keishan,
Taoyuan, Taiwan
Objective:
To provide quality data of artificial arthroplasties in a timely and continuous way is of paramount importance because they
are performed on highly demanding patients and would cause great loss with untoward conditions. This study was to
review the results of using multiple strategies to meet this need in a high volume teaching medical center.
Method:
This study was carried in a 3000-bed medical center that has more than 150 primary artificial arthroplasties by 17
surgeons in a month. Strategies including (1) Questionnaire of arthroplasty quality, (2) Prospective case auditing, (3)
Monthly meeting, (4) Root cause analysis (RCA) of sentinel case, (5) Disclosure of total knee quality indicators from
Taiwan National Health Insurance Bureau (DNHI), (6) Taiwan QIP, and (7) Self-reported Joint Registry Quality (JRQ)
were used to monitor and improve the quality of artificial arthroplasty. From 2006 to 2010, cases of artificial arthroplasties
were prospectively monitored until 3 months postoperatively. The results of the indicators from (5), (6), and (7) were
cross-examined for the cycle of the PDCA to generate new strategy for continuous quality improvement.
Results:
From 2006 to 2008, an infection rate of 1.4% was noted in 1488 knee arthroplasties. After questionnaires collection and
RCA of infection cases, it was found 81% had diabetes and infection elsewhere, 63% had doubts of breaching in the
sterility perioperatively, and 13% had inadequate use of prophylactic antibiotics. A prospective case auditing plan
implemented in 46 patients focusing on the integrity of care and procedure-based activities identified 5 pitfalls including
inadequate mask-wearing, inadequate skin preparation, overlooked laboratory tests, unnecessary operation room
trafficking, and wrong prophylactic antibiotic timing. A task-force team was then assigned by using the above mentions
strategies. Since September 2008, the team experimentally started the JRQ with 14 self-reported indicators in HIS (Health
Information System) on hip and knee arthroplasties. The indicators included prophylactic antibiotic, infection, fractures,
dislocation, neurovascular injury, and other complications. After fine tuning of the system, the JRQ was formally launched
in June 2009 to provide real-time results of the indicators that could be cross-examined with the results of DNHI and TQIP.
Ever since the implementation of these multiple strategies, the awareness of the quality improvement in arthroplasties
improved greatly. The adequacy in timing of prophylactic antibiotic improved from 86% to 100%. The yearly superficial
infection rate improved from 1.4% to 0.71% in 2008 and to 0.36% in 2009. The yearly deep infection rate improved from
1.4% to 0.47% in 2008 and to 0.24% in 2009. The quarterly infection rate was 0.61%, 0.62%, and 0.23% for superficial
infection and 0%, 0.21%, and 0% in the first 3 quarters of 2010. Similar trends could be found by cross-examining the
data from DNHI and TQIP.
Conclusion:
To implement a quality improvement program in a high volume hospital involving 17 different surgeons and their teams
was a difficult task. To identify the quality targets with consensus needed collaborations from the caring teams. This study
found the multiple strategic approaches for quality assurance was effective in aligning the goals from all involving
members. By integrating the data base registry program into the HIS, the data entry and retrieval of the JRQ became
timely and continuously. The data can be cross-examined with the publicity data from TQIP or DNHI to enhance the
feedback mechanism during the quality control processes. This study found that the use of diverse strategies can
encourage all members to participate and generate new plans for continuous quality improvement.
0241
Hospitals’ benchmarking: it can be conducted.
1
2
3
4
Susana Lorenzo-Martinez , Julián Alcaraz-Martinez , Concepción Fariñas-Alvarez , Aurora Calvo-Pardo
1
2
Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain, Hospital Universitario Morales Meseguer, Murcia,
3
4
Spain, Hospital Sierrallana, Cantabria, Spain, Hospital San Jorge, Huesca, Spain
Objective:
Benchmarking is defined as the process of identifying, learning, and adapting outstanding practices and processes from
any organization, to help an organization improve its performance. A hospitals benchmarking network, “Red.7”, between 7
public Spanish hospitals was established in 2006 (H. El Bierzo -León, H.U. Morales Messeguer - Murcia, H. San Jorge Aragón, H. Sierrallana - Cantabria, H. Son Llàtzer -Mallorca, H. Valle del Nalón - Asturias, and HU Fundación Alcorcón Madrid), signing the European Benchmarking Code of Conduct. Project included qualitative benchmarking (comparing
processes with high frequency and impact: Hip fracture -HP and Chronic Obstructive Pulmonary disease -COPD) and a
quantitative approach (general performance indicators).
Methods:
Choosing an optimal benchmarking partner requires a deep understanding of the process being studied and of the
benchmarking process itself. We used a four-phased approach: 1) fulfilling a detailed questionnaire, data collection, data
analysis and reporting, and adaptations of study findings. Evaluation was performed using a pre-post study. Selected
indicators were process average length of stay (ALOS) –days-, in HP average preoperative length of stay (APLOS) -days,
and average diagnostic related group weight (AW). 2 periods were compared (2004/07 vs 2008/10). Results show the
mean difference between them.
2) Hospitals were compared using the EFQM model as a reference in the quantitative approach, analyzing the indicators
in use in the participating hospitals. Indicators used qualitative and quantitative information (i.e.: surveys, administrative
information, outcomes). Indicators were defined, and cards for all of them were fulfilled to guarantee comparability.
Results:
Hospitals comparability was checked, although some differences were found.
1) COPD: Two hospitals of the network showed the best results and were considered as a benchmark (ALOS 2007: 6.58
and 7.22 days, AW: 2.25 and 2.33 respectively). In 3 hospitals (42.9%) the drivers were selected, adapted and
implemented.
Hip fracture: One of the hospitals showed the best results (ALOS 2006: 8.9 days, average preoperative length of stay 1.8
days, AW: 3.27). Some of the drivers identified were: special operating room with open programming, an internal
medicine specialist to attend those patients, and clinical pathway implementation. Identified drivers were adapted and
implemented in 2 hospitals. Globally, average ALOS was reduced in 3 hospitals (-0.25 to -4.57). APLOS was reduced in 4
hospitals (-0.03 to -1.21), while AW increased in 4 hospitals (+0.05 to +0.72).
2) The indicator set is formed by 36 indicators, each hospital can use it to compare itself with the others and to make selfcomparisons along the time. However not all the participating hospitals can be compared in all of them.
Conclusions:
The EFQM Excellence Model let us detect a gap in the comparison of results and best practices between hospitals, each
hospital can identify good practices, analyzing them in the benchmark, deciding whether or not to implement them. There
was improvement in some of the hospitals that adapted the identified best practices, in order to obtain improvement, it is
essential to adapt the identified drivers carefully.
The study was funded by the Spanish Ministry of Health Research Agency. PI 08/90419
0251
Six-sigma approach to improve process of outpatient clinic and patient’s satisfaction
Serae Noh, Moon Seok Park, Chin Youb Chung, Kyoung Min Lee
Seoul National University Bundang Hospital, Bundaug, Gyeonggi-do, Republic of Korea
Objective:
The number of outpatients to orthopedic department has been increased due to aging population, which has put
considerable burden on the capacity of outpatient clinic. And this could cause prolonged waiting time and patients’
dissatisfaction. This study was to investigate the effect of six-sigma approach to improve the process of outpatient clinic
and patients’ satisfaction in orthopedic outpatient department. Our final objectives were to increase the number of
outpatients clinic while improving patients’ satisfaction.
Methods:
To increase the number of patients several promoting methods such as multivision on elevators, posters at the entrance
of the outpatient clinic, physicians’ broadcast appearances, healthcare lectures, and volunteer abroad program were
adopted. Additional six new outpatients clinic sessions and walk-in clinics were created to avoid losing patients from
shortage on booking slots. For all sessions, the maximum capacity for patient enrollment was increased by 40% and the
starting time was put forward one hour to 8 a.m. Meetings were held with neighboring private clinics to reinforce
conciliation and a new icon for sending back patients to former clinics was created on electronic medical record (EMR).
To improve patients’ satisfaction, measures were adopted focusing on reducing waiting time. For this, exercising
education by the physician was replaced by self-educational practice in the waiting room through educational leaflets and
video. These materials were also uploaded on the webpage of the hospital.
The weekly average number of outpatients and the average waiting time were evaluated from 2009 and 2010. The
cusmtomer satisfaction index and the financial outcome were measured.
Results:
The weekly measured average number of outpatients was increased by 300 from the former average of 893 patients and
the average waiting time was reduced to 17.6 min per patient from previous 19.4 min. There were 30% increase in
number of patient visited to our center and 25% increase in number of surgeries and inpatients compared with those of
the previous year. Overall, these increases surpass the hospital’s natural growth of 1.5%. The customer satisfaction index
in 2010 scored 77.1 and did not significantly differ from that of 2009 scored 77.4.
The error rate which comes from adding the number of patients treated in the clinic and their waiting time was improved
by 58.6 % and the sigma level by 37.5%. The profits would be around 1.3 million dollars from the increased number of
outpatients, and around 40 thousand dollars from the increased number of inpatients.
Conclusion:
Besides achieving our goals, we have improved our communication skills among different departments by having regular
meetings and workshops during six sigma activity. In employee satisfaction survey, 85% of the respondents said that the
number of outpatients has been extensively increased and felt that their workload has been increased to 77% as well. In
addition, 85% of them said that the six sigma activity was necessary and 77% felt that the activity was satisfactory or very
satisfactory.
0252
Risk Management and Clinical Characteristics of Patients Treat for In –hospital Accidents
Hui-O Lin, Chia –Yun Hsieh, Kuan –Chih Chung, Jia-Shou Liu
Kaohsiung chang kung memorial hospital, Kaohsiung, Taiwan
Objective: To analyze the causes, process, management, and prevention of future urgent events for clinical patients who
had unexpected treatment for accidents in the hospital.
Materials and Methods: By using a retrospective cross-section study, a total of 225 patients was collected in a
southern Taiwan medical center between the years 2004 and 2007.
Results: The highest rate in each category was “hospitalized patients” (52.9%) based on allocation. The ward (35.6%)
was the most common site of accidents and “fainting or unconsciousness” (33.0%) was the most frequent cause. The
most common disposition of patients was “continued hospitalization” (22.7%) after treatment. Patients between “31~40
years old” (19.1%) were treated more often than those in other age groups and more accidents were seen in June (12.9%)
than in other months.
Compared with admitted patients who did not need urgent help, patients treated after in-hospital accidents were found to
have longer hospital stays by 22 days.
Conclusion: We suggest enacting a program to improve the rate of accidents at commonly reported sites in the hospital.
This may enhance hospital capability in treating patients who have accidents and reduce relevant medical expenses. To
decrease the rate of accidents, hospital administrators need to enhance patient safety by reinforcing standard procedures
concerning the care of patients with an unstable clinical status. Also, continued education of hospital staff on this issue is
important.
Reference:1. Behrman, Nelson Textbook of Pediatrics: 17th edition 2003.
2. Wallis LA, Healy M, Undy MB, Maconochie I. Age related reference ranges for respiration rate and heart rate from
4 to 16 years. Arch Dis Child 2005;90:1117-21.
3. Pediatric Vital Signs eTool on eMedicineNet.com Available at : http://www.emedicinehealth.com/
pediatric_vital_signs/article_em.htm. Accessed December 20, 2010.
0253
The Effect of Leadership Behavior and Safety Culture on Safety Performance－The Case of Nurse
1
2
1
1
Cheng-Chia Yang , Yi-Hsuan Lee , Suh-Er Guo , Mei-Fen Huang
1
2
Kuang-Tien General Hospital, Taichung County, Taiwan, National Central University, Department of Business
Administration, Jung-Li City,Taoyuan, Taiwan
Objective: Organization leadership could lead members to achieve goals and optimal safety performance through safety
culture. Most of the research references the variance between patient safety perceptions and patient safety behavior, but
there has been very little discussion about the association among leadership behavior, safety culture, and safety
performance in the healthcare industry. Leadership behavior and safety culture are both important to affect safety
performance, thus, neither can be ignored if safety performance is to be achieved. This has also been proven in highreliability organizations. In recent years, many publishes focus in reporting patient safety culture, but lack of publishes to
investigate the relationship with leadership of health care industry, safety culture and safety performance, our study is
according reference to design a scale to investigate these three dimensions.
Methods: The study was performed via questionnaire investigation. The transformational leadership was referenced by
Multifactor Leadership Questionnaire (MLQ).The safety culture scale was constructed based on scales such as the SCS,
PSCHO, and SAQ. The individual perception of organization safety culture includes organization management, safety
communication, and management commitment. The individual perception of organization safety performance includes
“proactive safety performance” and “reactive safety performance” which dimensions adapt from the work of previous
literature. This study is a cross-sectional study, By mailing 705 questionnaires to the Nursing staff. Confirmatory factor
analysis (CFA) is carried out to test the factor structure, Construct composite reliability is significant, factor loading >0.5,
result indicate an acceptable model fit.
Results: These implicated the organization more respect to promote safety culture with safety system and employee has
more positively safety behavior in their work that brings higher safety performance. The model also revealed
transformational leadership has no directly effect on safety performance, however, indirectly effect relationship between
transformational leadership and safety performance through safety culture. This model accounted safety culture a
stronger direct effect on proactive safety performance than reactive safety performance which for 59% of the variance in
proactive safety performance. The percent of the variance in safety culture was explained by transformational leadership
and transactional leadership was 45%. The directly and total effect of transactional leadership on safety culture was 0.37.
However, the direct and total effect of the transformational leadership on safety culture was 0.55, respectively. Thus,
transformational leadership stronger direct and total effects on safety culture than transactional leadership. The
transformational leadership has stronger indirect and total effect on proactive safety performance than transactional
leadership and it also on reactive safety performance. The result support the leadership behavior and safety culture can
affect on safety performance. The relationship between the leadership behavior and safety performance, however was
mediated through safety culture.
Conclusions: The study proved leadership, safety culture and safety performance have relations, that differ from
previous research explore safety performance between organization and individual. The behavioral safety performance
can be a safety performance measurement and evaluation, thus, the study measure safety performance by reactive
safety performance and proactive safety performance, proactive safety performance is used to measure organization
safety management system, the reactive performance is used to measure individual safety behavior with safety
participation and safety compliance. Our study have good fit of model to support the model by testing in nursing unit, that
confirms the safety culture effect safety performance, the transformational leadership and transactional leadership
mediated effect safety culture. The study reveals model can apply to healthcare facility while promoting and implementing
patient safety culture.
0254
A Randomized Controlled Trial of an integrated care model of Telephone Nursing Support Service for Psychiatric
Patients Discharged from an Acute Psychiatric Unit in Pamela Youde Nethersole Eastern Hospital
Po Yee Ivy CHENG, Chui Kwan KAN, Yin Chun Loretta YAM, Chung Pun Tony NG
Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
OBJECTIVE: To evaluate the effectiveness of a novel Telephone Nursing Support Service (TNSS) by psychiatric nurses
for discharged mental health patients with regard to qualify of life, social functioning and re-hospitalisation.
METHODS: TNSS was designed to support patients and caregivers through regular telephone care intervention, to
enhance knowledge about symptom deterioration and need to seek early intervention and improve compliance to clinic
follow-up. A prospective randomized controlled trial was conducted in four acute psychiatric wards of Pamela Youde
Nethersole Eastern Hospital (PYNEH) without additional resource. Patients scheduled for discharge and with diagnoses
of affective disorders or schizophrenia and related disorders were randomized into Intervention Group (IG) and Control
Group (CG) after informed consent. Both groups received Pre-Study Assessment before discharge and usual care postdischarge for a 12-week study period. IG received additional interventions: (1) Patient and caregivers empowered using
cue card and problem checklist to detect changes in symptoms and (2) At least 7 sessions of outbound telephone nursing
consultations in 12 weeks, utilising protocols developed by psychiatric nurses and doctors and with backup by case
doctors and/or community psychiatric nurses (CPN). IG and caregivers were encouraged to call TNSS whenever required.
Evaluation for IG and CG: (1) Post-Study Assessment with validated psychometric measurements through face-to-face
interview by Community Psychiatric Nurses (CPN) and (2) Patient Satisfaction Survey. The following data were collected:
number of out-bound and in-bound phone calls, types of service provided, Short-form Health Status -12 (SF-12) on quality
of life, Life Skills Profile -16 (LSP-16) and Specific Level of Function (SLOF) on social functioning, compliance to
psychiatric clinic follow-up, subsequent re-admission rate and duration of hospital stay.
RESULTS: From 1 Dec 2009 to 31 Nov 2010, 279 patients were recruited and randomized (IG 148 and CG131). Of these,
165 [IG=97 (Affective Disorder 44, Schizophrenia 53); CG=68 (Affective Disorder 19, Schizophrenia 49)] completed PostStudy Assessment (59.1%). In total, TNSS made/took 2712 out-bound calls (18.3 per IG patient) and 163 in-bound calls
(1.4 per IG patient) to/from patients and caregivers. Average call duration was 10 minutes (Range 3-30 minutes). The
most frequent advice given included: coping skills, symptom & stress management in 2430 calls; supportive counseling
(1982 calls); and advice on drug use (1082 calls). Early psychiatric follow-up was organized for 54 patients and 38 were
referred to emergency department. Compared to CG, IG with affective disorder showed improvement in interpersonal
functioning (p < 0.01) and overall SLOF (p < 0.05), while IG with schizophrenia showed enhanced physical functioning (p
< 0.005). At 12 weeks post-discharge, there was no difference in compliance to psychiatric follow up, but there was a
favourable trend in the re-hospitlaisation rates: At 12 weeks post discharge, 43 patients [IG 20 (13.5%), CG 23 (17.6%)]
were readmitted while at 31 Jan 2011 80 [IG 35 (23.6%), and CG 45 (34.4%)] were readmitted.. In the Patient Satisfaction
Survey, IG considered telephone care support to be convenient and important on symptom management and medication
related problems.
CONCLUSIONS: The pilot Telephone Nursing Support Service (TNSS) model provided integrated care management for
post-discharge mental health patients and their caregivers, and acted as a link between primary and secondary care and
the community. TNSS was welcomed by patients and demonstrated preliminary effectiveness in symptom management
and social functioning, with a favourable trend in reducing re-hospitalisation. A larger, more rigorous and better resourced
study should be conducted to confirm these findings, which will inform the Hospital Authority on future post-discharge
support and management of mental health patients.
0256
Applying Healthcare Failure Mode and Effect Analysis (HFMEA) to improve the Hemodialysis service quality in
the regional hospital
1
2
1
1
Chin-Wen Huang , Hao-Yun Kao , Pi-Yu Chang , Shang-Juh Huang
1
2
Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, Kaohsiung Medical University,
Kaohsiung, Taiwan
Objective: Current accreditation standards issued by the Taiwan Joint Commission on Hospital Accreditation (TJCHA)
required hospitals to carry out proactive risk assessments on high-risk activities each year, because hospital managers
generally do not have the sufficient knowledge or level of comfort for conducting proactive risk assessments. In December
2010, a regional hospital in South Taiwan, which conducted the Healthcare Failure Mode and Effect Analysis (HFMEA) on
the hemolysis process to reduce the risk of problems inherent in the procedure. The objective of this study was to identify
and evaluate the impact of potential clinical risk, which improves the quality of care and to assure patients’ safety.
Methods: The analysis was conducted by HFMEA methodology and core steps: (1) Define the HFMEA topic: examining
the potential factor effected of the risk reporting system. (2) Assemble the team: members of this project by doctors,
nurses, and members of the administrative center. (3) Graphically describe the process: this project was based practice
standard operating procedures to depict the flow chart. (4) Conduct a hazard analysis: the team identified several
potential failure mode for each management process, and using hazard analysis matrix to estimate that severity and
occurrence for each failure mode. (5) Identify actions and outcome measures: the RPN (Risk Priority Number) method
requires the analysis team to use past experience, and engineering judgment to rate each potential problem according to
three rating scales: (a) Severity, which rates the severity of the potential effect of the failure. (b) Occurrence, which the
likelihood that the failure will occur. (c) Detection, which rates the likelihood that the problem will be detected before it
reaches the end-user/customer. Rating scales usually range from 1 to 10, with the higher number representing the higher
risk. The specific rating descriptions and criteria are defined by team to fit the processes that are being analyzed. After the
ratings have been assigned, the RPN for each issue is calculated by multiplying Severity, Occurrence and Detection.
(RPN = Severity × Occurrence × Detection)
Results: There were four failure modes been identified by HFMEA procedure assessment. The key failure modes were
Undefined Risk Estimate System (RPN= 560), Mistake Risk Level (RPN=320), Effect Monitor System (RPN=300),
Undefined Contact Window (RPN=512). After control strategies for every failure mode and implementing corrective
actions, the index number of RPN has significantly decreased. Undefined Risk Estimate System (RPN= 40), Mistake Risk
Level (RPN=32), Effect Monitor System (RPN=12), Undefined Contact Window (RPN=8). Moreover, according the data
from Patient Safety Systems, since June to August 2010, after implementing corrective actions, the average time of risk
response had significantly decreased from 648 minutes to 120 minutes, and also, extent of damage related costs had
decreased US$4,200 to US$0.
Conclusions: HFMEA analysis of incidents is a powerful method of learning about healthcare organization and its
professionals. It takes a team’s efforts to improve patient safety continuously, which avoid damages and doing procedure
corrections from happening by finding potential pitfalls. HFMEA is a systematic, continuous and proactive risk analysis
method that leads directly to strategies for enhancing patient safety. Experience with the methodology suggests that
training is needed for it to be used effectively. As the result, it could effectively improve the quality of healthcare and
ensure patients’ safety.
0257
The relationship between severity score and costs of patients with mechanical ventilator in medical intensive
care unit in Taiwan
Pi-Yu Chang, Jong-Rung Tsai, Ming-Shyan Huang
Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
Objectives: The development of critical care improves the patients’ outcomes but the costs also are increasing
simultaneously. For critical ill patients, severity score play an important role in predicating their mortality. CCI (Charlson
comorbidity index score), APACHE-II (Acute Physiology And Chronic Health Evaluation II) and SOFA（Sequential Organ
Failure Assessment score）are the most popular severity scores in medical intensive care unit. However, there are
limited results about relationship of severity scores and the costs of critical ill patients? The aim of study is to analysis the
relationships of different severity scores and costs of medical ICU patients.
Methods: Betweeen 2009-Jan and 2010-Dec in Kaohsiung Medical University Hospital in southern Taiwan, 462 MICU
patients with mechanical ventilator were included. We recorded age, gender, severity scores (CCI, APACHE-II and
SOFA), clinical outcomes (ICU length of stay (LOS), hospital LOS, ventilator days, ventilator weaning rate, mortality) and
costs. Data is expressed as mean ± SD or n (%). Differences in continuous variables or categorical variables between two
groups were tested using independent t test or χ test or ANOVA. Receiver Operating Characteristic curve (ROC) was
2
used to determine the cuff-off valve of individual severity scores for predicting the mortality. Besides, we use logistic
regression analysis to explore any potential confounder for ICU mortality of patients.
Results: Total 462 patients (male: 62.9%) were included in this study. The average age was 65 ± 16 (range: 24-96). The
mortality predicting cuff point of each severity scores are 23 (APACHE-II (AUC=0.63, sensitivity=0.69, specificity=0.57)); 7
(SOFA (AUC=0.66, sensitivity=0.89, specificity=0.41)); 1 (CCI (AUC=0.50, sensitivity=0.45, specificity=0.40)). Multivariate
models had shown APACHE-II>23 (Odds: 2.356, 95%CI: 1.480-3.441), SOFA>7 (odds: 3.702, 95%CI: 2.217-6.183）.
The daily cost (New Taiwan dollar (NTD)) was higher in APACHE-II>23 group (n=223) in comparison with the
corresponding data of Group APACHE-II≦23 (NTD 19,792±16,933 versus NTD 13,469 ±17,641, p ≤ 0.05）, but shorter
hospital LOS（14±12 days versus 16±12 days, p ≤ 0.05）. SOFA>7(n=286) group also had higher daily cost（NTD
18,817±15,692 versus NTD 12,788 ±19,739, p ≤ 0.05）, shorter hospital LOS（14±11 days versus 18±13 days, p ≤
0.05）and ICU LOS（6±5 days versus 7±5 days, p ≤ 0.05）. Patients with high CCI (>1) had longer ventilator days（9±9
versus7±5, p ≤ 0.05）.
Conclusions: In addition the prediction power of mortality, our study had shown severity scores can be used to predict
the medical fee of ventilator critical ill patients. The higher of severity scores were correlated to the daily cost of ICU. This
may help clinicians to control the medical cost more effectively under the limitation of medical care budget.
0258
Reduce the rate of DM patients with poor glycated hemoglobin
Chen Ming-Hui, Liu Su-Yen, Shen Jia-Lin, Chou Chien-Wen
Chi-Mei Medical Center, Tainan City, Taiwan
Objective: The purpose of this program is to reduce the rate of poor glycated hemoglobin (HbA1C＞9.5 %) with DM
patients.
Methods: This program is carried out by a combination of doctors, nutritionists and diabetes educators. From March 10,
2009 to December 6, 2009, use the PDCA approach to improve the patients (255 people ) with poor glycated
hemoglobin who participate diabetes care program of fourth quarter of 2008 (1744 people) in a medical center
of southern Taiwan. Explore the reasons, we find the unbalanced diet is the most factor, irregular exercise and
medication without proper adjustment are the second and the third reasons. Further we investigate into the that
of these three reasons and find true reasons are not to comply with the diet, food type errors, often eating
outside, lack of health education in the information; the patients think that labor is equal to exercise, too lazy to
move, physicians did not emphasize the importance of exercise; fear of injections by themselves and be afraid
of causing kidney or eye broken after an insulin injection. To play a team cooperation , do the implementation of
various countermeasures. For example: setting a variety of diseases, the most common food standards and
lesson plans; to teach a proper eating outside skill; to give the nutrition counseling records; do not get a long
prescription with irregular exercise patients;making a daily exercise record; physicians have to remind patients
to do exercise and clarify the misconceptions; to stress the difference between injection and not injection ;
holding a small focus groups; to share patient’s success stories; let patients to see the needle and hold the
patient's hand to practice injection.
Results: The rate of poor glycated hemoglobin fall down from 14.6 % to 6.2%.
Conclusions: We know the team group to have great contribution in improving the poor glycated hemoglobin of patients
with DM. In the future, I hope to improve the patients with other quarters, not just the fourth quarter of 2008.
0259
The Design and Evaluation of an Individualized Medication Instruction sheet-A Pilot Study
Pei-Chia Lee, Gin-Ying Lee, Yin-Chih Liu, Wan-Ru Wu
Landseed Hospital, Ping-Jen City, TaoYuan County, Taiwan
Objective:
The goals of this study were (1) to design an individualized medication instruction sheet (IMI), and (2) to evaluate its
effectiveness.
Background:
Improving the safety of using medications is the first priority among Taiwan patient safety goals in 2011 announced by the
Department of Health. Patients’ involvement in their own healthcare should be considered when designing an effective
patient education tool. This report was the project of an innovative individualized medication instruction sheet (IMI)
developed by our hospital and its pilot evaluation results.
Methods:
Two phases were involved in this study.
Phase one was the individualized medication instruction sheet design.
1. Patient needs and concerns of IMI were obtained by interviewing inpatients, pharmacists, and nurses.
2. Health informatics specialist in our hospital was consulted in order to ensure the daily updated IMI can be printed out
through our information system by primary pharmacists.
3. All of the medications were organized on A4 size sheets. Inpatients received their daily updated IMI from evening
shift nurse with oral explanation. IMI contained
(1) characteristics of medication (e.g. picture of each pill, unique marks on pill, pill size or shape),
(2) prescription information (e.g. frequency, dosage, before or after meal), and
(3) Warning (e.g. side effects, not taken with certain food or drink).
Phase two was the evaluation of the IMI.
1. Single group post measurement design was performed for our pilot study, and patient satisfaction was used as
outcome indicator.
2. Participants were hospitalized adults patients between September and October in 2010. Participants received survey
questionnaire on the day of discharge.
Results:
1. Seventy patients were enrolled in this study. 51 (72.8%) completed the survey questionnaire.
2. More than third forth (79.2%) participants felt the IMI help them more understand what medications they took, and
what should be caution while taking.
3. 72.2% of participants satisfied that the IMI contents meet their needs for medication information.
4. 81.6% of participants satisfied with medication education provided by a combination of oral explanation and IMI. In
addition,
5. 77.6% of participation said they had been discussed with health care providers (e.g. doctors, nurses, or pharmacists)
about their medication since they felt being involved with their own health care.
Conclusions:
To ensure the patient medication safety, patient education is always concerned. The results in this study indicated that
IMI was not only had greater satisfaction by patients but also encouraged patients got involved in knowing personal care.
Key words: individualized medication instruction sheet, medication education, medication safety
0262
Enhancement of Personal Information Security – e-media Disposal Campaign at Kowloon East Cluster Hospitals
Cheng Ka Pui Gladys, Lee Elvix
United Christian Hospital, Hong Kong
Objective:
To uphold the data protection principle in handling electronic patient information, Information Security and Privacy (ISP)
office of Hong Kong Hospital Authority (HA) Kowloon East Cluster (KEC) has organized an ISP Campaign called ‘e-Media
Disposal Day’ to sanitize all unused electronic storage media.
Methods:
With the advanced features of today’s healthcare operating system, using electronic media for storing patient information
has become a common practice. However, data privacy will be violated if electronic storage media is poorly managed.
Accidental release of these media could lead to unauthorized disclosure of patient information.
The FADE cycle was utilized to enhance information security in handling electronic storage media.
1. Focus
Data collection from international privacy incidents, HA Advanced Incidents Reporting System (AIRS) and near miss
cases for identification of improvement areas.
2. Analyze
Fish-bone diagram was used as a tool to analyze “Man, Machine, Material and Method” in safeguarding electronic data
security.
3. Develop: Solutions
A. Policies and Guidelines
 Ensure all departments and staff followed the newly endorsed Standard Operating Procedure (SOP) on proper
handling of electronic storage media.
 Reinforce HA on retention policy for medical record and data protection principle.
B. Education and Promulgation efforts
 Organized an one-off activity to sanitize all electronic storage media which is no longer necessary in KEC.
C. System design
i.Stock-taking was carried out to record the amount of unused electronic storage media in March 2010.
ii.The campaign was presented in the Medical Committee and Department Operations Managers meeting.
iii.A multi-disciplinary working group was formed with members of medical, nursing and allied health
representatives.
iv.SOP on proper handling of electronic storage media was drafted and endorsed in the Cluster ISP Committee.
v.A debriefing session was held in November 2010 to promote the SOP on proper handling of electronic storage
media.
4. Execute
Periodic evaluation and monitoring on the effectiveness of the SOP by walk round and compliance audit.
Results:
With the overwhelming response, the campaign has sanitized more than 7000 pieces of electronic storage media.
(including 2500 floppy disks, 1800 projector slides, 1500 video tapes and over 1400 other electronic media). Workflow
and practice on handling of electronic storage media was standardized in KEC.
Conclusions:
The e-Media Disposal Campaign not only enriched our staff’s knowledge on information security and standardized the
workflow and practice on proper handling of electronic storage media, it also successfully inculcated and fostered the
information security culture in KEC.
0263
A Program to Decrease the Blood Infection Rate of Port-A from an Evidence-Based Practice
Yu-Yi Lai, Pei-Pei Lu, Shu-Hui Lee, Wen-Pin Yu
Chang Gung Memorial Hospital, Taoyuan, Taiwan
Infection is the most troublesome issue in Port-A care, and also one of the main reasons for the inability to continue to use
a catheter. This hospital’s Port-A care employs gauze to cover the injection spot; the dressing is changed every three
days when the dressing becomes damp and dirty. From 2007 to 2008, most of the in-hospital ward infections were blood
infections: 3.14% and 4.26%, respectively; 80% of the patents have Port-A care. Is there any better care model than the
current Port-A care? This question triggered the author’s curiosity. According to the clinical scenario, the author set up two
PICOTs. First: a blood cancer patient with Port-A placed in his/her blood vessel. The question is whether the transparent
dressing or the sterilized gauze used to cover the injection spot during the hospitalization period is associated with the
Port-A catheter blood infection rate. Second: a blood cancer patient with Port-A placed in his/her blood vessel and
covered with the transparent dressing on the injection spot. The question is whether changing the dressing every 7 days
or 3 days during the hospitalization period is associated with the Port-A catheter blood infection rate. Authors searched
the Medline, PubMed, Cinhal, Cochrane library, and found 39 related papers, and extracted those released between
2000-2009 with a grade above level II, in English, and involving patients aged 20–65 with the central venous catheter
(CVC) placed. Finally, two studies were reviewed in this paper. The author undertook an in-depth review of the critical
appraisal skills program (CASP), and found that Gillies et al. (2003) do not include the research conducted after 2000 in
their literature, whereas Vokurka et al. (2009) do not mention if the distribution method must be kept confidential. Also,
due to the intervention, the study could not be blinded. Gillis et al. (2003) indicate that the use of the transparent
polyurethane dressing or gauze and tape to cover the CVC did not show statistically significant variance. Furthermore,
according to Vokurka et al. (2009), covering the polyurethane semi-permeable occlusive dressing on the CVC and
changing the dressing once or twice a week did not have significant variance in positive catheter blood cultures. Once
Port-A is infected, the patient’s hospitalization period needed to be extended. The author had worked on an improvement
scheme from July 15, 2008 until February 29, 2009. With this scheme, in addition to changing the dressing on the
catheter injection spot into the transparent dressing, the author also held catheter care seminars, prepared catheter care
briefings, and established a feedback and surveillance mechanism. Given the fact that the blood infection rate declined
from 4.26% to 3.22%, the frequency of the dressing change was extended to 7 days, the cost of consumptive materials
dropped from NTD304.94 to NTD219.27, medical waste was also reduced from 155 grams to 60 grams, and nursing
manpower cost decreased from NTD108.8/time to NTD80.83/time. The nursing time saved can be used to provide
sanitary education and psychological counseling for patients. At the end of this project, the new catheter care method had
been promoted to the hospital.
0265
Additional medical costs associated with Falls/Slips based on administrative profiling data at a rural university
hospital in Japan
1
2
3
4
Masahiro Hirose , Yuichi Imanaka , Haruhisa Fukuda , Eun-Hwan Oh
1
2
Shimane University Hospital, Izumo, Shimane, Japan, Kyoto University Graduate School of Medicine, Kyoto, Japan,
4
Institute for Health Economics and Policy, Tokyo, Japan, Hyupsung University, Hwaseong, Gyeonggi, Republic of Korea
3
Objective: Additional medical costs associated with Falls/Slips within a rural university hospital are explored for past
three years.
Methods:
We used 1,442 in 2007, 1,330 in 2008, and 1,669 collected incident reports in 2009 at a university hospital with 606 beds
including 40 psychiatric beds in Shimane Prefecture, Japan.
Out of 4,441 incident reports, 1,190 (382 in 2007, 399 in 2008 and 409 in 2009) reports were related with Falls/Slips. They
were classified into 0-5 levels according to level classification. Level 0 indicates nothing happened and level1 indicates
something happened but no damage was done with the patient. Level 2 indicates medical examination and /or medical
observation were required. Level 3a indicates mild-degree medical care was required and level 3b indicates considerabledegree medical care was required. Level 4 indicates serious medical care was required and permanent or temporary
disability. Cases with over level 2 (590 cases) were required somewhat medical care and medical examination, but 566
cases were identified and analyzed.
With regard to 566 cases with health care services, we explored their incident reports and profiling administrative data in
order to calculate their additional medical cost which is not related with primary disease. And, if necessary, we checked
up their medical charts. Medical cost mainly consists of administration fee, medication fee, injection fee, treatment fee,
surgery fee, examination fee, diagnostic imaging fee, admission fee according to the insurance medical fee schedule
under the universal health care insurance in Japan.
Results:
Number of admissions and length of hospital stay were 9,738 and 19.3 days in 2007, 10,051 and 18.5 in 2008, and
10,563 and 17.1 days in 2009. Incident rate with Falls/Slips was 2.15 patient-day for three years. Of 1,190 cases for
Falls/Slips, the cases for Falls/Slips are classified 460 cases with level 2, and 124 with level 3a, and 6 with level 3b,
respectively. Cases with over level 2 are required to be cared and examined under medical observation.
Additional medical costs for Falls/Slips were 109492 USD (233 of 1,190 cases were required additional medical costs) in
2007, 2008 and 2009. And average medical cost per case was 469 USD. Furthermore, according to level of injury,
average additional medical costs are 135 USD* (level 2, 156 cases), 861 USD (level 3a, 72 cases), and 5287 USD (level
3b, 5 cases). Average medical costs are directly calculated from the insurance medical fee schedule under the social
insurance system.
From the viewpoint of clinical health care services, diagnostic imaging fee with level 2 and 3a were provided with medical
financial resources. And diagnostic imaging fee with level 2 was 19699 USD (93.4% of all medical costs with level 2:
21081 USD), and that with level 3a was 14041.90 USD (22.7% of all costs with level 3a: 61993 USD). Total Surgery fee
with level 3b was 18184 USD (68.9% of all costs with level 3b: 26398 USD). *USD: U.S. dollar
Conclusions:
Therefore, total amount of additional medical costs for Falls/Slips is 0.11 million USD at our hospital for three years, and
additional medical cost with level 3a and 3b was 80% (0.088 million USD). Therefore, it is suggested that hospital
administrators have to take appropriate measures to prevent patients with level 3b from Falls/Slips. The project including
this study on additional medical costs associated with falls is going on in collaboration with other teaching hospitals.
0266
The project for improving the success rate of “Door to Balloon”
I-CHING YANG, I-Ying SHEN, Chia-Chi KUO, HUi-Man CHEN
Chi-Mei Medical Center, Tainan, Taiwan
Objective: Acute myocardial infarction (AMI) is the major reason of sudden death in coronary artery disease. Door to
balloon (D2B), which means the AMI patient has to be sent to catheterization laboratory within 30 minutes after arriving to
the hospital and started to proceed Percutaneous Coronary Intervention (PCI). This project is to improve the success rate
of D2B.
Methods: According to Advanced Cardiac Life Support (ACLS), patients who have AMI have to be medicated within 30
minutes after arrival, and being sent to the catheterization laboratory within 60 minutes and finish PCI within 90 minutes.
Therefore, emergency and critical care accreditation required the hospital to complete the medication treatment of AMI
patient within 30 mins and sent to the catheterization laboratory for PCI preparation. According to the statistic from June
st
th
st
1 to June 30 2009, the success rate of D2B was 20%. Therefore, a project team is organized on July 1 2009 to
improve the D2B process. We figured out the following problems: 1. Inadequate experience of the triad nurses about
acute chest pain, 2. Unfamiliar of the medical personnel about the procedure of D2B, 3. Insufficient information delivery
st
th
system & 4. Lack of teamwork. Therefore, from November 1 , 2009 to June 30 2010, the following interventions were
done. 1. Introduction about the concept of Team Resource Management (TRM), 2. Adjustment of the D2B procedure, 3.
Three education conferences for triage nurses, 4. Five demonstration of D2B procedure, 5. Examination & interpretation
of complete EKG within 10 minutes, 6. D2B back-up system of medical personnel, 7. EKG image delivery system, 8.
Paging system of catheterization laboratory personnel, 9. Setting up of treatment kit, 10. Emergent elevator setting, 11.
Regularly analyse the data of D2B and held case conference every month.
Results: After the intervention of this project, the D2B success rate has increased from 20% to 80% in July 2010,
70~80% in August to November 2010 and eventually reach 100% on December 2010 and January 2011, which has
reached the purpose of this intervention.
Conclusion: The results showed that this project effectively increased the efficiency of teamwork in treating AMI patient
and therefore reduced the duration needed for D2B procedure. We also anticipated that this project could improve the
prognosis of patients who have AMI and improve the quality of care. In the future, we will keep improving on the
procedure of D2B by the concept of TRM.
0268
Early Initiation of Maternal-Newborn Skin-to-Skin Contact in Delivery Suite and Breastfeeding Rate of Tuen Mun
Hospital
SIU Sau Mei, Esther, AU YEUNG Kam Chuen, IP Sau Lan, Joan, TANG Fong Ying, Rose
Department of O&G, Tuen Mun Hospital, Hospital Authority, Hong Kong
Objective:
In line with the Hospital Authority (HA) annual breastfeeding survey in March to evaluate the compliance rate on practice
the step 4 of the Baby Friendly Hospital Initiative (BFHI) Global Criteria (WHO/UNICEF 2006) for promoting, supporting
and protecting breastfeeding among HA hospitals of Hong Kong.
Definition of standard:
Mothers in Delivery Suite who had uncomplicated vaginal deliveries within half-hour of birth, should be given their babies
with skin contact for at least 30 minutes, and offered help to initiate breastfeeding.
Method of data collection:
1. A standard data collection form was adopted which was developed and revised annually by the Lactation Consultants
group of HA hospitals.
2. Data included total number of deliveries, mode of delivery, option of infant feeding method, initiation time and duration
of skin-to-skin contact, reasons of delayed or not initiated skin contact were collected for analysis and evaluation.
st
st
3. Survey period was from 1 to 31 March 2010 and data included all live deliveries.
4. The coming survey will be conducted in March 2011.
Results:
-
There were 459 deliveries for the month of March 2010 in Tuen Mun Hospital (TMH). Overall 90.8% mother-baby was
given skin-to-skin contact within one hour after delivery and 73% could be early initiated within half an hour
immediately after the birth regardless their mode of deliveries.
-
Compliance rate with regard to the standard criteria was shown increasing from 1.4% in 2009 (same survey period) to
10.2% in 2010.
-
To compare with the 2009 annual HA breastfeeding survey results from the 8 HA hospitals with obstetrics unit,
average mean of initiating skin-to-skin contact in Delivery Suite was 62.2% and the compliance rate was 12%.
Conclusion and improvement measures:
This format of annual survey exercise to audit the standard practice among HA hospitals was commenced since 2006.
The compliance rate of TMH on the WHO global standard criteria step 4 was not the highest one. However the exclusive
breastfeeding since birth to postnatal discharge shown increasing from 8.7% to 28.5% as well as the annual
breastfeeding rate upon postnatal discharge was rising from 56.2% to 74.8% in the year 2006 to 2010 respectively.
Purpose of early initiation skin-to-skin contact immediate after delivery not only aimed at facilitating successful
breastfeeding, it also targeted to promote the early maternal-child bonding and grasped the golden moment to reinforce
the value of breastfeeding for the non-chooser.
0270
Promote nursing quality in reducing the incidence rate of pressure ulcers
Wen-Pei Huang, Wen-Ling Chuang
Chi Mei Medical Center, Tainan, Taiwan
Objective: Nursing department had officially built the wound care team to in charge of patient skin care since 2003. The
objective is to present the outcomes and the strategies in how to promote the nursing quality in reducing the incidence
rate of pressure ulcers.
Methods: The implementation of educational guidance, quality control team and the operating standards set by PDCA
steps to develop standards for pressure ulcer prevention, besides, hospital agreed to replace the mattress. In 2010, a
computerized information system has completely developed to strengthen and reinforce the functions, such as pressure
ulcer picture upload; computerize operation and management, to assist the clinical staffs to work with wound care.
Results: After the implementations, the results of pressure ulcer incidence rate was decreased from 0.35% - 0.56% to
0.10% -0.31%(low central limit –up central limit).
Conclusion: Pressure ulcers is the most common complication of many chronic diseases, pressure ulcers will extend the
recovery of patients, increase family burden, nursing hours and medical costs, early nursing assessment of whether the
high risk for early delivery of prevention measures to avoid pressure ulcers is very important. Pressure ulcer is the
significant index for nursing care. Through the quality management by applying the wound care specialist, PDCA
standards and computerize facility, to assist the clinical practice to promote the nursing care of patients.
0276
Use of Caring Model to Reduce the Incidence of Incontinence Dermatitis of a Certain Internal Medicine Ward
JAN IE FN, Liou Yan Shan, Chen Yi Jhih, Chu Chun Chun
Chimei Hospital, Tainan, Taiwan
Objective:
Long-term illness is usually accompanied by incontinence. The frequent skin exposure to excrement will lead to
incontinence dermatitis at anus and perineum, as well as the symptoms of pain, redness and swelling, decortication, etc.
When patients experience incontinence or diarrhoea, if caregivers change diapers independently and lack cleaning skills,
and nursing staffs lack the competence to provide instructions or fail to assess whether caregivers have difficulties in
implementation, patients are likely to experience incontinence dermatitis. Therefore, an ad hoc team was established in
order to reduce the incidence of incontinence dermatitis.
Methods:
1. Establishment of an ad hoc team.
2. Scales and questionnaires were designed according to literature review. The on-site inspection was conducted from
September 13, 2010 to October 15, 2010. The analysis found that there was a lack of nursing staff’s care cognition,
care procedures, care instruction tools, devices, and control mechanism.
3. Intervention pre-test: the incidence of incontinence dermatitis was 35.7%, the accuracy rate of implementation of care
by nursing staff was 44.4%, and 95.2% of caregivers indicated that nursing staff seldom spontaneously show concern
or assist them in implementation of care.
4. Intervention measures: care procedures for incontinence dermatitis were established, in-service education, periodic
case discussion, role-playing activities were held, and nursing care instruction leaflet and CDs were edited, control
mechanism was set up, and relevant devices were increased.
5. Intervention post-test: the incidence of incontinence dermatitis was reduced to 15.6%, the accuracy rate of
implementation of care by nursing staff was improved to 87.5%, and more than 85% of major caregivers were
satisfied with the spontaneous assistance provided by nursing staff.
Results:
1. Incidence of incontinence dermatitis: a total of 32 patients experienced diarrhoea from November 19, 2010 to
December 19, 2010 and 5 of them experienced incontinence dermatitis. The incidence was 15.6% and the expected
objective was achieved.
2. To increase the accuracy rate of nursing staff’s implementation of care for incontinence dermatitis: the members of ad
hoc team conducted on-site inspection on nursing staff’s implementation of care for patients with incontinence
dermatitis. It was found that the accuracy rate was increased to 87.5%.
Conclusions:
With the implementation of in-service education, establishment of skin care procedures for incontinence dermatitis, and
the improvement in nursing measures by illustrations in this project, it was found that nursing staffs’ ability to care for
patients with incontinence dermatitis was significantly improved. The implementation of this project further increased the
interactions between nursing staff and patients’ family, established good nurse-patient relationship, and substantially
contributed to the care for patients. It was advised that the training of incontinence dermatitis-related knowledge and care
ability should be provided for all the nursing staff in the hospital. In addition, qualified educators at Internal Medicine Ward
should be cultivated to improve care competencies, strengthen the nature of care, and further improve care quality and
satisfaction.
0277
Early defibrillation in the wards by nurse-initiated defibrillation: application of health technology
PF LAU, CC LAU, Bonnie CHENG, KK CHAN
Hospital Authority, Hong Kong
Objective:
To achieve, by applying health technology, early defibrillation by nurses in the wards before the arrival of doctors.
Background:
The American Heart Association (AHA) introduced the concept of the chain of survival for more than a decade. A rapid
and timely linkage of the four elements namely ‘early recognition and activation of emergency response system’, ‘early
CPR’, ‘early defibrillation’ and ‘early ACLS’ is utmost important and essential to increase survival rate of patients suffering
sudden cardiac arrest. AHA emphasized that ‘one minute delay in giving defibrillation to patients with shockable rhythm
means about 7-10% decreases in survival rate’. Though early/prompt defibrillation by medical staff is expected in acute
hospital setting, it is not uncommon that there will be a delay when waiting for the doctor to arrive. Nurse initiated
defibrillation is uncommon locally. The impact of immediate defibrillation initiated by nursing staff is not thoroughly studied.
The resuscitation committee of a major acute hospital designed a programme to enhance patient safety by allowing
nurses who had undergone a special training could use a specific type of defibrillator with selectable manual/advisory
mode to deliver shocks to patients found collapsed in the wards, before the arrival of doctors.
Methods (Health technology applied):
In order to ensure safe and appropriate shocks to be delivered by nurses in the absence of doctors, the committee
recommended the use of defibrillators with manual and advisory modes combined technology. A manual/advisory
defibrillator allowed users to choose either manual mode or advisory mode. In advisory mode, the machine may interpret
rhythms; select pre-determined energy level and charge up automatically. Then the operator is advised, via visual and
audio prompts, to press the ‘shock’ button after ensuring environmental safety. Advisory mode does not allow the
machine to charge or to advise a shock in the presence of non-shockable rhythms.Safety
Results:
Since February 2009, about 450 staff nurses (38%) from both general and psychiatric streams of the hospital attended the
special training and learned to use a specific type of defibrillator. More than 20 sets of such specific defibrillator of unique
brand and model have been added to cover most of the clinical area even where staff members have less rhythm
recognition skills or defibrillators are infrequently used. Since commencement of training in early 2009, totally three
patients received nurse-initiated defibrillation using advisory mode had been documented. Two out of the three patients
gained return of spontaneous circulation or ROSC. One of them survived till hospital discharge. No inappropriate
deliveries of shocks or complications relating to defibrillation have been reported since implementation.
Conclusions:
By application of appropriate health technology, early defibrillation by nurses in the wards was achieved. Although the
number of defibrillation attempt was small (only 3 documented cases), one out of the three patients survived till hospital
discharge. Nurse-initiated defibrillation by using appropriate health technology is a safe, achievable and important lifesaving measure to enhance quality of service in hospital settings.
0278
Title: Enhanced Patient Falls Management: Attaining the Next Level with Strategies and Innovations
Teresa FY Li, Alexander Chiu, WH Seto
Queen Mary Hospital, HKWC, Hospital Authority, Hong Kong SAR, China
Objective
To enhance patient safety by reducing fall incidents in hospitalized patients through the planning, development and
implementation of a multi-disciplinary Enhanced Patient Falls Management Program (EFMP)
Methods
A continuous quality improvement approach is adopted. Data on patient fall incidents is obtained through the Hong Kong
Hospital Authority’s corporate Advance Incident Reporting System (AIRS) and analyzed to identify improvement
opportunities and actions. The multi-disciplinary Patient Safety Subcommittee (PSS) advises on the strategic planning
and development of EFMP; monitors its implementation and evaluates the results of the improvement actions.
Strategic Planning on Fall Prevention and Development of the EFMP
In the course of strategic planning aimed at formulating enhanced fall prevention program, the PSS has:

Decided that the desired state is to formulate a comprehensive and flexible patient falls prevention program which
covers patients from admission to discharge, and to community

Verified the current patient falls situation by the regular clinical audits and on-site incident review. The fall incident
reports and audit findings are widely promulgated to raise frontline staff for awareness on patient fall risks and
prevention strategies

Explored and formulated various care pathways and measures on fall risk identification and prevention, which were
implemented through various pilot runs and projects and then evaluated and systemized to form the EFMP
Implementation of EFMP
The following steps are taken to successful launch EFMP:

Regular staff communication, discussion and training are organized to effect the necessary changes and consensus
in implementing EFMP

A network of Patient Safety Link Nurses (PSLN) and Ambassadors (PSA) within the hospital and the community
partners (such as Occupational Therapists, Community Geriatric Assessment Team (CGAT) and Community Nursing
Services) is established to enhance the continuity of care to the high risk patients.

Innovative measures such as the Obligatory Physiological Activity Round (OPAR), the online Patient Safety Corner in
the hospital home page and the Patient Safety Newsletter are used to effectively promote fall prevention

Nursing staff and support staff members in the clinical areas are given ownership of falls prevention subsequent to
the implementation of the OPAR to regularly check and provide assistance to the patient’s physiological needs
Results

With the implementation of EFMP, staff engagement and awareness on falls prevention increased. Fall prevention
has become an organized, systematic and evaluable job design for nursing and support staff within the EFMP which
has proven effective in reducing relating fall incidents. The average patient fall rates dropped from 0.75 per 1000 bed
days in 2006 to 0.53 in 2010. The compliance rates of falls prevention documentation improved from 67.51% to
90.15% for the same period. The successful EFMP was awarded `Extensive Achievement’ (EA) in the Hospital
Accreditation in 2010 by the Australian Council on Healthcare Standards.
Conclusions
Patient fall is one of the top hospital and patient risks that warrants concerted staff efforts and support from top
management in order to reduce risk and prevent harm to the patients. The EFMP, guided by the continuous quality
improvement approach, has demonstrated to be an effective program in reducing patient fall incidents.
0283
Pilot Study on Introducing Community Health Call Centre Support to Residential Care Homes for the Elderly
Joan Ho, Loretta Yam, Chun Por Wong, Patty Kwong
Ruttonjee & Tang Shiu Kin Hospitals, Hong Kong, China
Objectives: To evaluate the effectiveness of a pilot integrated post-discharge support by telephone to residents at high
risk for recurrent emergency admissions in elderly homes in Hong Kong
Methods: Elderly homes in Hong Kong are either partially funded by (or accountable to) the government (“subvented”,
30%) or privately operated (70%). All subvented homes and 80% of private homes are supported for 44-hour/week by a
geriatrician/nurse-led community outreach team from the Hospital Authority (HA), the Community Geriatric Assessment
Service (CGAS). The HA Community Health Call Centre (CHCC) has a successful 3-year track record of delivering
integrated support to elderly patients at high risk of emergency readmission within 28 days of discharge from acute
medical and geriatric wards back to their own homes. In this pilot study, the same risk prediction tool, the Hospital
Admission Risk Reduction Programme for the Elderly (‘HARRPE’) was used to identify private home residents with
HARRPE score ≥0.17 (high-risk) at discharge. CHCC nurse has direct access to up-to-date individual patient care
information through the HA Electronic Patient Record System, and delivers advice on drug management and care in the
home, coordinate/organize fast-track clinic attendance, outreach services or direct hospital admission where appropriate.
An Early Symptom Detection Checklist (ESDC) was designed by geriatric and CHCC nurses. Private homes in the control
group (CG) received conventional CGAS service whereas homes in the intervention group (IG) had the following
interventions: (1) HARRPE residents were actively followed-up by a CHCC nurse within 48 hours of discharge to provide
care advice and support based on 80 protocols designed by geriatricians and geriatric nurses; (2) staff were trained in the
use of the ESDC to facilitate timely report of changes in their residents’ conditions to CHCC; (3) staff had to direct all
enquiries to CHCC; and (4) CGAS nurses originally assigned to IG conducted other value-added services such as
medication reconciliation programs on discharge of the HARRPE residents. CG and IG were followed up for 90-days after
the study. The following data were collected: number of inbound and outbound calls, types of services delivered by CHCC,
effectiveness of ESDC, utilisation rate of healthcare services by residents, and satisfaction survey of staff of the homes.
Results From Nov 2009 - April 2010, 10 private homes (1,002 residents) were recruited, of which five were assigned to
IG (610 residents) and 5 to CG (392 residents). Demographics of both groups were similar. In total, 773 calls were made
(64.6% outbound, 35.9% inbound) and average call duration was 8.7 minutes. Advice given to the RCHEs including
reinforce to use community support for 417(53.9%) calls, drug management in 289 (37.4%) calls, health education
especially based on the ESDC in 350 (45.3%) calls, arrange clinical admission for 547(0%) calls, see visiting doctors.
The project showed effectiveness in reducing hospital utilization with decrease in 13% of AED attendances, 20% of AED
admissions and 24% of non-AED admissions. Satisfaction survey showed that RCHE staff appreciated advice on drug
management the most, followed by health education. RCHE staff were happy with information on community resources
for their residents.
Conclusion
CHCC contributes significantly to improving the quality of healthcare delivered by ensuring suitable professional staff to
go to the right place at the right time for the delivery of care. CHCC, as a supporter to CGAS, is a workable solution to
manage the escalating demands from RCHEs.
Changing established work practices in RCHEs experienced great difficulties and required much effort to modify the
existing communication system and to build up trust from RCHEs and CGATs. The focus on after-hours services before
seeking to rollout during the day-time hours may be an easier way to be implemented in a wider scope of public hospital
clusters.
Extension of the pilot
In order to manage the winter surge and avoiding unnecessary admissions to hospitals, the above pilot project was
extended to all private RCHEs (88 no. with 6191 residents) with some modifications on its service delivery mode in Dec
2010 (5-hr support for 79 with CGAT service, full support for 9 RCHE without CGAT service). All high risk residents
receive post discharge follow-up calls from CHCC within 24-48 hours upon their discharge. Only 9% of patients served
were advised to attend A&E (5.9%) or to be directly admitted to hospital (3.1%).
0285
Comparison of hand skin injury between rub and scrub sterilizing techniques in operation room staffs
Mei-Hui Peng, Cheng-Heng Chung
CHI-MEI MEDICAL CENTER, Tainan, Taiwan
1. Background:
Hand sterilizing technique is a basic technique of surgical preparation. With poor hand sterilization, the cost may be an
elevation of surgical infection rate. Furthermore, the hospital stay time and medical cost would rise rapidly.
Thus, a correct hand sterilizing technique is crucial. The technique should eliminate both the temporary and the inherent
nature of the hand flora efficiently.
Traditionally, brushing technique was carried out by soft nylon hair brush to brush against hand skin directly. We use 4%
povidone iodine (PI) or 4% chlorhexidine gluconate (CHG) as antimicrobial agent. The technique was quite painful and
would cause skin damage. We operation room staff suffered from allergic reaction and desquamation a lot.
Recently, an aqueous alcoholic solution was introduced to the market with a rubbing technique to perform hand
sterilization. The rubbing technique was expected to do less harm than frequent hand scrubbing. We would like to tell the
difference of hand skin damage between rubbing and scrubbing technique.
Second, the method:
The empirical method uses Pub Med, Cochrane and CEPS three databases, type the keywords include "surgical hand
disinfection techniques", "hand rubbing", "Transitional surgical scrub", "hand scrubbing", "microbial counts", "skin
condition "And restrict the conditions for the RCT, Systemic review, Meta analysis to obtain 22 documents, skimming
through the article title and summary of removing non-relevant documents, were eventually adopted five appraisal.
2. Method:
Literature review was done in EBM way with PubMed, Cochrane, and CEPS. The key words used include: surgical hand
disinfection techniques, hand rubbing, Transitional surgical scrub, hand scrubbing, microbial counts, skin condition. The
ranges searched were RCT, systemic review, and meta analysis.
We concluded 22 literatures. After exclusion by title and abstract, we reviewed 5 of them to make our conclusion.
3. Result:
According to the literatures, there are significant differences in cost, effectiveness and hand skin damage of health care
personnel. The use of sterile water and brushes wash their hands before surgery is not needed (Furukaw et al.2005).
Means of hand rubbing with a brush than the number of bacteria disinfection will be less and less time is relatively simple
(Carro C et al.2007). (Berman 2004) also pointed out that a soft nylon brush, hair brush in hand and did not reduce the
number of microorganisms. (Larson et al.1998, Larson 2001) also proposed the use of soft wool and nylon brush and
sponge brush can cause skin damage. But the effectiveness of sterilization is alike. (Ogawa Furukawa Long Qing Xian Ye
Xiao Lu Seto Jia Yantian Tajiri 2004, CDC 2002) With method of hand rubbing, the number of bacteria disinfection will be
less than scrubbing. And it's relatively simple, and time is short.
4. Conclusion:
The documented use of the traditional surgical scrub brush or sponge is more ineffective. It also causes more skin
damage and desquamation. The use of rubbing technique would be as efficient as scrubbing technique but does not
cause more desquamation. Therefore, it is recommended that hand sterilization with rubbing technique is an alternative
way to replace scrubbing technique if you care about your peeling hand.
0288
Safety and Quality Managing Program on Prevention of Infiltration and Extravasation in Intravenous Treatment in
O&T Department
Kwok Hang Lung, Man N W, Wong K F, Kwan C S
Queen Elizabeth Hospital, Hong Kong
Objective :
Intravenous treatments, including intermittent injection or continuous infusion of intravenous fluid, medication and blood
products, are common in Orthopaedic and Traumatology Unit. However, inappropriate administration and leakage might
cause soft tissue injury. Infiltration and extravasation are common complications of intravenous therapies. The outcomes
of these complications range from local irritation to amputation. The most serious consequences include permanent
disfigurement and loss of function which requiring reconstructive surgery. Apart from lengthened hospital stay, lawsuit
consequence may be resulted. In 2008 till now, there were over 10 patients suffered from difference stages of infiltration
or extravasation were transferred to our department.
Method :
A safety and quality managing program has been carried out in O&T Department, QEH (From July-Sept 2009). Brief
contents of the program include establishment of an evidenced based practice guideline on prevention and management
of infiltration and extravasation, a briefing session on the content of the guideline to all nursing staff capable for
intravenous therapies. A pre & post tests on staff knowledge questionnaires were performed. For ensuring quality
assurance and continuous improvement, an audit form was established. All nursing staff responsible for administration of
intravenous therapies including intravenous fluid infusion or intravenous medications was included in the auditing process.
Medical colleagues are collaborated in the practice of intravenous access establishment.
Result and Discussion :
No new incidence of infiltration and extravasation (Grade 2 or above) is reported after commencement of the program.
Outcome indicators include staff performance as well as incidence of infiltration and extravasation. Both knowledge and
practice of nursing staff regarding prevention of infiltration and extravasation are satisfactory (Fig 1 &Fig 2). The usual
practice on managing intravenous therapies was updated.
Staff compliance (Mean %)
Staff Knowledge (Mean Score)
n=43
100
91
90
88
100
80
100
55
98.5
98
73
60
100
99
97
60
47
45
98
97.4
51
40
Pre
Post
20
96
95
Mean Rate
94.4
94
93
92
0
Ward A Ward B Ward C Ward D Dept.
Fig 1
91
Ward A
Ward B
Ward C
Ward D
Dept.
Fig 2
Conclusion :
This safety and quality managing program is aimed to increase the awareness of the potential serious complications of
intravenous therapies as well as to reinforce safe practice among nursing professionals in order to ensure patient safety,
as well as to minimize the incidence of infiltration and extravasation. With significant staff performance and no new
incidence of infiltration and extravasation is report. The outcome of the program is positive and is worth to introduce to
other departments in our hospital.
0290
Hospital nurses’ knowledge translation: Evidence based practice, error occurrence, and job satisfaction
Jee-In Hwang
Kyung Hee University, Seoul, Republic of Korea
Objective: to determine relationships between evidence based practice (EBP) use, medical error occurrence, and job
satisfaction among hospital nurses.
Methods: This study employed methodological triangulation. A cross-sectional questionnaire survey was conducted to
collect data on nurses’ competencies regarding patient centeredness, teamwork/collaboration, quality improvement, and
safety; work climate perception; error occurrences, and job satisfaction. EBP use was measured using Evidence-Based
Practice Questionnaire developed by Upton & Upton (2006). The participants were 600 nurses working at two teaching
hospitals, Seoul, South Korea. Subsequently, 13 nurses in the two hospitals were sampled using snowballing method as
key informants and they were interviewed. Logistic regression analysis was performed to determine the relationship
between EBP use and error occurrence. Multiple regression analysis was conducted to examine the relationship between
EBP use and job satisfaction. Interview data were analyzed using qualitative content analysis.
Results: The survey response rate was 98.5% (n=591). The overall score of EBP use was the mean 3.9 (SD=1.1) on the
7-point Likert scale. At the item level, critical appraisal was the lowest (3.5±1.2), and information sharing was the highest
(4.3±1.4). The EBP use was positively correlated with nurses’ competencies regarding patient centeredness (r=0.43),
teamwork/collaboration (r=0.40), quality improvement (r=0.46), and safety (0.39). Logistic regression analysis showed that
there was no significant relation between EBP use and error occurrence. However, multiple regression analysis revealed
that EBP use was a significant factor influencing job satisfaction. From the interview data, two themes regarding EBP use
were emerged: professionalism and confidence. The main themes emerged as barriers of EBP use included busy work,
limit of nursing job, difficulties of EBP application due to the differences from the real practice. The themes emerged as
facilitating factors were continuing and repetitive learning, improvement initiative, seniors’ leadership, and educational
support at both individual and organizational levels.
Conclusions: The findings demonstrated that nurses’ EBP use was not popular in clinical practice. To facilitate EBP use
in hospital nurses, nurses’ competencies regarding patient centeredness, teamwork/collaboration, quality improvement,
and safety need to be improved through educational programs. In addition, hospital managers should take into account
the barriers and facilitators identified. These efforts contribute to the improvement of nurses’ professionalism and job
satisfaction.
0293
Implementation of an Experience feed back committee (EFBC) and impact on prevention and risk management in
radiotherapy.
Marie Delgaudine, Eric Lenaerts, Nicolas Jansen, Philippe Coucke
CHU, Radiotherapy Unit, Liège, Belgium
Objective: To implement an Experience feed back committee (EFBC) to identify, record and analyze systematically all
reported precursor events with as final objective to test and strengthen the security of the organization and the quality of
care for patients.
Methods: After definition of the general objectives, mainly the reduction of the precursor events (PE) including incidents
and accidents, we have identified and adapted the methodology in order to tailor it to the specificities of our department.
We then organized the collection and analysis of precursor events; started with EFBC meetings and decided to train the
members of EFBC with the ORION® analysis system with the staff of Air France Consulting. The management reassured
the staff that reports are aimed at creating awareness to safety and not designed to identify “a” responsible person to
“punish”. The registration chart was designed to ensure anonymity, confidentiality and reactivity.
Results: The first EFBC has been organized in January 2009. The majority of staff members quickly adopted the
reporting of precursors including physicians and physicists who are described in literature as participating less. This EFBC,
composed of a multidisciplinary staff of all professionals, has the task to select events considered as being of high priority,
to analyze events and decide the most appropriate correcting action and ensure its proper implementation. They monitor
and communicate on the 4 steps of the Deming wheel. On a period of 22 months, we collected 2026 PE with an average
of 92.1 PE per month of which less than 2% are incidents. We have implemented 317 improvement actions so actions
have been performed for more than 15% of PE. We have already observed a reduction in precursor events and we have
observed that correcting actions have more impact on PE related to administrative and treatment steps than on PE
related to sector organization.We are also able to achieve a mapping of steps considered as “risky” in our workflow. We
have identified 3 major indicators to evaluate the effectiveness of this approach: the number of precursor events by month,
the regularity of the reporting and the EFBC meetings, the number of improvement actions decided and carried out on
time.
Conclusion: The collection of precursors and the implementation of EFBC resulted in a fundamental change in the
culture of the department. It does not seek for individual mistakes but targets defects of the whole system. This EFBC is a
powerful management tool which is considered as essential to evolve in Quality and Safety. Specific parameters issued
from this approach are integrated to pilot and manage the department. The EFBC requires the active participation of all
health professionals and the involvement and continuous support of the management team. It enables to secure,
standardize and formalize our practices. It empowers staff to share and communicate on the corrective actions, to
implement and follow the effectiveness of these corrective actions on the long run. Prospects are now to sustain this
EFBC in the radiotherapy department but may also be extend to other department that treated oncological patients and
finally to the entire hospital. Next step is to share this experience of PE analyze and corrective actions with other national
and international radiotherapy departments and finally implement clinical audits.
0294
USE OF HANDHELD DIGITAL DEVICE AT BEDSIDE TO IMPROVE QUALITY OF NURSING CARE
LO WING KEE
UNION HOSPITAL, Hong Kong
Objective: To evaluate the effect on efficiency of nursing workflow, errors of drug administration, taking observation and
patient satisfaction after using a comprehensive program running on a PDA.
Methods: As the use of PDA had become increasingly popular, a program was developed on PDA for the care of
hospitalised patients. Wireless network is employed for data transfer. The functions of the program included taking photos
of patients, scanning of 2D barcode for identification, taking observations, tracking of drug administration, labelling of
specimens, retrieving laboratory and imaging results, scheduling of activities, alerts for outstanding tasks. The system
has been implemented for 1 year. The time required by the same staff on taking observation, retrieving clinical information
and administration of drugs in different wards were recorded. Incidence of drug dose omission, administration of drugs to
wrong patient and omission of taking observations were monitored for a year before and after implementation. Patients
were asked to complete a questionnaire about the system before discharge.
Results: It was found that the system reduced time consumed for taking vital signs by 31% to 50% and time for retrieving
clinical information by 36% to 61%. On the other hand, it increased the time spent on administration of medication from
9% to 18%. Incidence of drug dose omission has dropped from 4 per year to zero. Incidence of administration of drugs to
wrong patiend has dropped from 1 to zero per year. Incidence of omission of taking observation has dropped from 24 per
year to zero. 95% of patients reported feeling more safe and had greater confidence in our care with the implementation
of the system.
Conclusion: The use of handheld devices at bedside by nurses can improve efficency and accuracy of workflow by
reducing human errors. The system also gives patients better sense of security and higher satisfaction.
0301
Discussing the Effect of Improving the Level of Oral Care for Oral Cancer Patients who Received Surgical
Treatment
Yi-Chen Li, Yi-Ping Liu, Chiu-Ping Wen, Shu-Yu Chang
Chi Mei Medical Center, Tainan City, Taiwan
Purpose
The purpose of this study is to evaluate the quality of oral care for oral cancer patients who received oral surgery after
implementing the oral care protocol.
Methods
Oral health problems are the main physical issues of oral cancer patients after surgery. For improving the health quality
after surgery, the complete oral care is necessary. A purposeful sampling was used to assess 15 post oral surgery
patients’ oral status by using check list. The questions were identified after analyzing the current situation. An oral care
protocol was implemented to another group of 15 post oral surgery patients which including “providing oral care learning
handbook”, “organizing group teaching”, “establishing nursing quality control system” as well as “applying disposable
dental suction tube” and “dental models”.
Results
The quality of oral nursing care was improved after using oral care protocol. The incidence of patients with bad breath
decreased from 66.6% to 0%. The percentage of blood accumulation in the mouth decreased from 46.7% to 0% as well.
Moreover, only 6.4% of patients still suffer from dry and cracked lips, it was 40% before implementing oral care protocol.
The percentage of patients who choke while eating also declined significantly from 33.3% to 0%.
Conclusion
The purpose of oral care is to maintain the oral hygiene, avoid odor and infection in the mouth as well as maintain the
normal function of oral. In this study, the application of oral care improved the quality of oral nursing care. Furthermore,
nurses also learnt from this study that by using various teaching facilities and teaching strategies along with oral teaching
the quality of oral nursing care for post oral surgery patients can be improved remarkably.
0302
Improving the Accuracy of Oral Care for Post Surgery Patients by Nurses
Mei-Hsin Yeh, Mei-Hua Ting, Yi-Chen Li, Shu-Yu Chang
Chi Mei Medical Center, Tainan City, Taiwan
Purpose
Improving nurses’ knowledge of oral care and the accuracy of performing oral care for post-surgery oral cancer patients.
Methods
The patients who received oral surgery are prone to have halitosis caused by the secretions in the oral wounds.
According to the clinical observation, many patients have complained about oral care they received. The record shows
that there were up to 8 patients complained bad breath in the same time. Therefore, a checklist had been used to
examine this issue and the results indicate the accuracy of oral care which performed by nurses was 32% and the nurses’
knowledge of oral care was 29 points out of 100 points. Furthermore, a qualitative interview discovered the reasons which
cause poor oral care quality are “insufficient knowledge”, “lack of care standard”, “lack of learning tools”, “lack of control
system” and “lack of imitating aids”. After numerous academic researches and brainstorming, a series of measures have
been implemented to solve these issues including holding continuing education (classroom teaching and video disk),
establishing oral care standard, developing learning handbooks of oral care (with the photographs of standard care and
simple explanation), establishing oral care quality control indicators (the quality control group monitor the quality of care
monthly) and adding imitating aids (using teeth models as teaching aids).
Results
The implementation of the measures increased the accuracy of oral care skill from 32% to 100% as well as enhanced the
score of the knowledge of oral care to 98.45 points. The 28 post-surgery oral cancer patients who attended this research
have no complain of bad breath anymore.
Conclusion
Accurate and efficient oral care can decrease the incidence of oral wound infection and halitosis. As the result, the level of
patients’ comfort can be improved. By sharing this research and other associate information, all the nurses can
understand the importance of oral care for post oral surgery patients, review the clinical care knowledge and skills they
have as well as provide accurate oral care to patients.
0304
Project to Enhance the First-time Success Rate of Urine Sample Collection From the Urine Bag in Hospitalized
Children
Xu Ya Ting
Chi-mei hospital, Tainan, Taiwan
Introduction
Urine sample collections from children not toilet-trained are performed using the pediatric urine collection bag. When the
children are in diapers, acting out, or being soothed by rocking, nurses often face difficulties in checking the urine bag and
miss the urine voiding time. Frequent replacement of the adhesive urine bag is necessary due to loose or lost attachment
and is time consuming, a waste of medical supplies, possibly causing a delay in diagnosis and treatment and prolonged
hospital stay. It also leads to red or broken skin around the perineum, resulting in damage to children, complaints of the
family members, and even dissatisfaction of the medical team. The aim of this project is to increase the first-time success
rate of urine sample collection from the urine bag from 15.38% to 83.08%.
Methods:
According to the empirical analysis and literature review, we 1) developed specialty standards for techniques of urine
sample collection from the pediatric urine bag, including material preparation, skills of attaching urine bags, cautions and
care guides. 2) created the innovative "In-house Pediatric Urine Bag”, in which a sterile 3x3-inch gauze was placed using
sterile technique to absorb the urine 3) provided on-the-job education for Techniques and Cautions for Collecting Samples
From the Pediatric Urine Bag to reach a consensus and for return demonstration.
Results
First-time success rate of urine sample collection from the urine bag in the hospitalised children who were not toilettrained was 91.86%, reaching the goal of the project.
Conclusion
We had telephone interviewed some pediatric departments of medical centers and did literature review and found that
there was limited information about sample collection from the adhesive pediatric urine bag. Through this project, nurses
not only increased the success rate (91.86%) but also achieved knowledge and skills enhancement in collecting urine
samples using the method (score 100). Total hours per nurses spent on collecting urine samples were down from 10.7 to
1.89; indirect cost reduction of medical supplies was achieved from NTD39.96 per person to NTD14.33. Through this
innovative approach, we accomplished the goal of the project, enhanced quality of care, and lowered medical costs,
achieving triple wins.
0305
1
1
1
Patient and Staff Safety during Pandemic –Safer and Smarter Ways Ho SM , Leung LM , Leung KM , Law SL
Ward 13A, Isolation Ward, Department of Medicine & Geriatrics, United Christian Hospital
Sin Man Ho, Lok Man Leung, Ka Man Leung, Sheung Lan Law
11
United Christian Hospital, Hong Kong
Objectives
To enhance our staffs’ capability of handling infectious disease patients, the reliability of using checklists and “need to do”
lists and the proficiency in performing high risk procedures are tested.
Methodology
Initially, we reviewed our practices based on the experience in HSI pandemic. Some managerial and clinical procedures
such as Nasopharyngeal Aspiration (NPA) taking and Conversion of General ward setting to Isolation ward are identified
and formulated as checklists and ‘need to do’ lists. Then, experts from Hospital Infection Control Team are invited
comments on the checklists. Infection Control Nurses (ICN) and Ward Managers from various Medicines & Geriatrics
wards are invited to act as observers in the drill. After all, the checklists and ‘need to do’ lists are test run through the drill.
Post exposure prophylaxis (Tamiflu) distribution drill was included. Debriefing was then held after the drill to invite
feedback and comments from observers. A visit to Princess Margaret Hospital (PMH) was organized
Results
There were 22 nurses including managerial staff, front line staff and 9 supporting staff participated in the drill.
4 checklists and ‘need to do’ lists are validated as follows:
1.
Admission of high-risk case
2.
NPA taking
3.
Transfer of confirmed case to PMH
4.
Contingency plan: Conversion of 13A General to 13A Isolation
Feedback from our staff and observers are mostly positive. Skillful NPA taking is highly appreciated. Comprehensive
checklists are also highly valued. On the other hand, communication channels among various departments can be
modified. Regular intra-departmental training of outbreak management and deployment plan are also suggested.
Conclusions
Hospital visit provide us benchmarking opportunity. Regularly drills enable validation of our tools and reflection of our
practice. Together with the smart use of our tools can facilitate an effective and comprehensive workflow. Our staff can
provide quality care in safer and smarter ways.
Hospital visit provide us benchmarking opportunity. Regularly drills enable validation of our tools and reflection of our
practice. Together with the smart use of our tools can facilitate an effective and comprehensive workflow. Our staff can
provide quality care in safer and smarter ways.
0306
USING OF ROOT CAUSE ANALYSIS TO PREVENT SUSPECTED INCOMPLETE STERILIZED EVENT IN THE
PROCESS OF HYDROGEN PEROXIDE PLASMA STERILIZATION
Hsiu-ju Jen, Ching Ying Huang, Mei Yun Yu
Far Eastern Memorial Hospital, New Taipei, Taiwan
Objective
The purpose of this project was ensuring hydrogen peroxide plasma sterilization process (HPPSP) was effective and
successful at providing heat and moisture –sensitive items into all aseptic environment to reduce the risk of infection.
Method
This report is an experience of suspected incomplete sterilized event of HPPSP, that happened in the Central Service
Department (CSD) of a private medical center in September 2008. The methodology was conducted by Root Cause
Analysis (RCA) as follows:1) define the problem by interviewing all personnel to gather data and evidence, 2) create
tabular timeline to clarify final crisis, 3) brainstorm to find the risk, 4) analyze by whys tree to define the causes: lacking of
standard of operation of HPPSP, lacking of instructions of HPPSP in native language and lacking of the policy of
incompleted sterilized items, 5) analysis the most feasible, accessible and effective strategies by matrix, improve the
validity of the program by barrier analysis: create the standard of operation and instructions of HPPSP in native
language；design a table to record the residual amount of cassette to remind stuffs to change the cassette；create
standard of operation about transferring sterilized items between CSD and operation room；build up HPPSP
reprocessing chart of internal Chemical Indicator strip；design sterilized interpretative test kits of HPPSP to check on
CSD and operation room (OR) stuffs quarterly；organize relevant education and training.
Result
1. No suspected incomplete sterilized event happened after creating the standard of operation and instructions of HPPSP
in native language from Jan 2009 to September 2009. 2. 100％of CSD and OR stuffs could recognize HPPSP
reprocessing chart of internal Chemical Indicator strip correctly .3. 100％ of CSD and OR stuffs could interpret sterilized
interpretative test kits of HPPSP correctly. 4.Held 6 hours in office education of HPPSP reprocessing course, 3 hours in
CSD and 3hours in OR. Attendance rate of OR was 82％ and CSD was 86％.
Conclusion
Infection control management in hospital has been as an important implementation of patient safety in recent years.
Department of Health in Taiwan has set “patient safety” as one of the most priority of the year. Create standard of
operation of HPPSP, set up a friendly interface and in office education could reduce suspected incomplete sterilized event
rate. CSD staffs will be the safeguard of patient safety to decrease the infection rate of patients.
0307
A four-year action research project examining interprofessional learning (IPL) and interprofessional practice (IPP)
across a health system
Jeffrey Braithwaite, Mary Westbrook, Joanne Travaglia, Johanna Westbrook
Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia
Objective: We instituted an action research demonstration project and conducted an extensive formative and summative
evaluation of IPL and IPP in which we worked collaboratively in a team-based, researcher-industry partnership to
stimulate improvement and assess the development of interprofessionalism (IP) over a four year period.
Methods: After setting up the study in 2007 we administered a purpose-designed questionnaire to a cross-section of staff
1
2
in 2008, 2009 and 2010. The questionnaire comprised scales from Heinmann et al and Parsell and Bligh and questions
on other attitudinal and demographic variables. The key attitudinal scales were: Quality of Interprofessional Care;
Teamwork & Collaboration; Doctor Centrality; Professional Identity; and Roles & Responsibilities. We hypothesised there
would be improvements in IPL and IPP as measured by scores on these scales, with the exception of Doctor Centrality,
which we predicted would decrease over the research period. We conducted analyses of variance (ANOVA) and Duncan
Range tests to determine statistical significance.
Results:
Table 1: Results of ANOVAs comparing staff attitudes in 2007, 2008 and 2009
Table 1 presents the results
of the ANOVAs. There were
1,445 responses over the
2009
2010
2008
three years with an
(n=525)
(n=471)
estimated response rate of
(n=449)
32.1%. Scale scores did not
#
increase significantly yearQuality of IP Care
4.69
4.72
4.68
0.61
2,1284 0.545
on-year with the exception of
#
Roles & Responsibilities and
Doctor Centrality
3.17
3.08
3.29
9.43
2,1360 0.000*
Doctor Centrality. There
§
were clearer views about
Teamwork & Collaboration
4.15
4.21
4.15
1.70
2,1357 0.184
staff Roles & Responsibilities
§
in 2010 than in prior years
Professional Identity
4.00
4.04
3.96
2.91
2,1364 0.055
(p=0.048). The
§
comparatively higher means
Roles & Responsibilities
2.94
2.93
3.01
3.04
2,1380 0.048*
for supporting Teamwork &
#
§
* Statistically significant; 6 point scale; 5 point scale; Higher scores=agreement
Collaboration, having a nontribal Professional Identity,
and acknowledging the value of Quality of IP Care, indicate that respondents supported IP to quite an extent at project
inception. The Doctor Centrality scale measures whether respondents believe the physicians’ role is key and others’ roles
are to assist. A lower mean score suggests there is disagreement amongst respondents that medical dominance should
continue. These scores are just above the scale’s midpoint, indicating no strong beliefs in medical dominance. However
more respondents considered that the doctor’s role should be central in 2010 than previously (p=0.000).
Attitudinal scales
Mean scores
F
df
P
Conclusions: We believe this is the largest longitudinal study of its kind, thereby achieving a key study objective. It
demonstrates relatively strong support levels for IP in this health system. However, we found only slight improvement in
attitudes over time despite the expertise provided by a large action research project. According to these results, enabling
and measuring greater levels of IP across health systems over time is challenging.
References:
1. Heinemann GD, Schmitt MH, Farrell MP, Brallier SA. Development of an attitudes toward health care teams scale.
Evaluation & the Health Professions 1999;22(1):123-42.
2. Parsell G, Bligh J. The development of a questionnaire to assess the readiness of health care students for
interprofessional learning (RIPLS). Medical Education 1999;33(2):95-100.
0309
Reducing central line associated bloodstream infections and ventilator associated pneumonias by standardizing
practices: sustained success
Donna Armellino, Bruce Farber, Kenneth Abrams, Yosef Dlugacz
NS-LIJ Health System, Manhasset, NY, 11030, USA
Objective: To decrease central line-associated bloodstream infection (CLABI) and ventilator associated pneumonia (VAP)
with standardized practices in 22 adult intensive care units (ICUs) with over 330 ICU beds across ten hospitals.
Methods: A multidisciplinary Task Force representing each hospital worked to standardize evidence-based practices
guidelines for patients with a central line (CL) and those mechanically ventilated. A “Central Catheter Insertion Note,” that
included all aspects of the CL bundle to promote adherence to the documentation of the standard of care was written.
Each insertion was observed with a “Central Line Checklist” to ensure that the insertion requirements were followed. A CL
insertion kit, guaranteeing consistency of available materials was assembled. An interdisciplinary “Daily Goals and
Rounds Sheet” for CL and ventilator management was implemented to formalize the process into the day-to-day care and
create accountability for practice expectations. Other efforts included installation of alcohol-based hand gel in every
patient room and the use of employee hand hygiene competency. The message of zero tolerance for infections was
delivered with on-site education, discussion at the medical board and ground rounds, and self-learning modules through
the employee intranet.
VAP prevention focused on providing respiratory professionals with evidence-based guidelines for patient assessment for
early extubation, oral care for nursing, a protocol for sedation vacations, deep vein thrombosis prophylaxis, guidelines for
elevation of the head of the bed, early consideration for a tracheotomy, and patient mobilization. To prompt care, the ICU
flow sheet was modified to include all risk reduction elements.
To evaluate CL and VAP bundle compliance a web-based data collection tool and report were developed. Data entered
into the collection tool were transposed to a one-page summary report that displays data trends. When compliance with
the bundle was >95% monitoring was discontinued by external reviewers, but was maintained through internal oversight
and monitoring. As the initiative progressed additional processes were implemented. These included: a dedicated room
for CL insertions (when feasible), daily chlorhexidine baths, the use of a “scrub-the-hub” campaign with cleansing the CL
hub with alcohol for 15 seconds, and review of a CLABI with the interdisciplinary team to identify opportunities for
improvement. A uniform “table of measures” with consistent definitions to collect CLABI and VAP data across facilities
was developed to establish baseline and changes in the rates over time. To monitor CLABI and VAP infections, positive
microbiology specimens from the blood and sputum were reviewed to identify an infection based on the National Health
Safety Network definitions. The rate of CLABI was calculated as the total number of CLABI divided by the total number of
CL days, multiplied by 1,000.The VAP rate was calculated as the total number of VAP divided by the total number of
ventilator days, multiplied by 1,000.
Results: The results are statistically significant (p<.001) for 2004 versus 2010. From January 2004 to December 2010 the
annual CLABI decreased from 3.25 to 0.95. The VAP decreased from 5.64 to 1.64.
Conclusions: The outcome objectives of this targeted intervention resulted in a steady and significant decrease in CLABI
and VAP which translates to improved patient safety. The Plan-Do-Check-Act methodology was successful due to
leadership commitment, the team approach to identify and overcome barriers, focused communication, standardized
approach toward care, dedication to educational efforts, plus the availability of new tools, data collection procedures, the
creation of reports summarizing activities performed at the bedside. This experience has enhanced knowledge and
implementation of evidence-based guidelines within the patient care team to decrease the risk of infection and served as
a guide to duplicate the effort in the non-ICUs.
0312
The incidence and nature of in-hospital adverse events in Portugal: contribution to drive research and innovative
approaches to safety improvement.
Paulo Sousa, António Sousa Uva, Florentino Serranheira
1
2
National School of Public Health, Lisbon, Portugal, CMDT, Associate Research Laboratory, Lisbon, Portugal
Objective: To estimate the incidence and preventability of adverse events in Portuguese hospitals and based on that to
contribute to drive research and to develop innovative approaches in this healthcare setting.
Methods: The study was carried out at three acute hospitals in the Lisbon area. A two-stage structured retrospective
medical records review was done based on the use of 18 screening criteria. A random sample of 1.695 charts,
representative of the 70.103 hospital admissions between 01 January 2009 and 31 December 2009, were analyzed. The
power calculation of this study was based on the results of the Canadian Adverse Events Study, assuming an incidence
of AEs of 8% with a confidence interval of 95%. Oversampling was carried out, with the expectation that 10% of charts
would be unusable. The sampling frame includes all admissions for patients over 18 years old who had a minimum stay in
hospital of 24 hours. Hospital admission with a most responsible diagnosis related to obstetrics or psychiatry were
excluded.
In the first stage, the nurses assessed each medical record for the presence of at least one of the 18 criteria, indicating a
potential adverse event. In stage 2, each record with those criteria was reviewed by a physician in order to confirm the
presence of an adverse event; estimate their impact and determine their preventability, accordingly to the definition
established previously. The degree of agreement between the reviewers in each stage was calculated using kappa
coefficient.
Results:
In the preliminary analysis the main findings are: i) one or more screening criteria were found in 384 (23%) charts; ii) in
the second stage a 9,8% incidence of adverse events (AE’s) was found; iii) from those, around 46% were considered
preventable; iv) more than a half of all AE’s were related to surgical procedures, drug errors and health care acquired
infection (HCAI); v) most of AE’s (68,4%) resulted in no physical impairment or disability, or in minimal impairment which
was resolved during the admission or within one month from discharge; vi) 6,1% resulted in death; vi) the reliability of the
assessment of screening criteria by nurses (first screening) was considered good (α 0.64); vii) among doctors (in the
second stage) the reliability of determination of AE’s and their preventability were moderate (α 0.49 and α 0.45,
respectively). Our results are similar to the findings of previous studies particularly the UK and the Danish study on the
rate, preventability and main consequences of AE’s.
Conclusions:
In Portugal, there is an overall awareness and a growing concern about patient safety issues. Although judgment of
presence of AE’s is difficult, retrospective patient medical records studies are currently the gold-standard methodology
available to assess their incidence. This study shows that AE’s in these Portuguese hospitals affect nearly one in ten
patients. A substantial part of these events are preventable. The main results of this study will be a contribution to provide
a foundation and driving force for research and frontline initiatives in order to reduce harm to patient. Since a large portion
of the AE’s are related to surgical procedures, drug errors and HCAI, funds and efforts should be allocated to
interventions aimed at reducing those types of events. The systematic use of surgical checklists and the audit of some
complex surgery procedures; the adoption of a computerized system for drug dispense; the development and
dissemination of well establish standards for drugs administration; and new strategies for improve infection control are
some examples of such initiatives.
0313
Integration of two international models of accreditation in a quality system management structured
for improvement.
Daniela Akemi Costa, Fabio Luís Peterlini, Jair Rodrigues Cremonin, José Carlos Oliveira
Hospital Sao Camilo, Sao Paulo, Brazil
Objective:
Demonstrate the experience of a hospital implementing the quality system management applying concepts and
fundamentals of two international models of accreditation (Accreditation Canada and Joint Commission International).
Methods:
The main strategy was the participation of most operational staff, stimulating creative ideas to match common aims,
approaching educational process for employees by standardizing the best practices in assistance of patients and family,
to approach administrative and technical professionals in the same discussion and finally disseminating safety culture for
all staff.
Therefore, seven teams and eleven groups of improvement have been formed with the autonomy to analyse flows,
indicators/results, review process and introduce best practices from international references. Two presentations of teams
and groups have been scheduled for every week and efforts must be shown to the leadership with the purpose of
breaking barriers, facilitating the means and promoting best results.
Results:
Both models have changed the perspective of patient-centered care introducing another way to understand the
information flows, different from the traditional model where the Quality Practices and Safety Policies were created and
applied by a number of people from the Quality Department and Board of the hospital for almost 5 years. The new noncentralized model has increased the participation of more than 120 direct people planning, standardizing, comparing,
disseminating and improving process, in an interdisciplinary view, within two years, promoting discussions in all levels of
the organization.
Conclusions:
Adoption of policies, practice and management in a simple language, common to any accreditation model provide the
belief in people that quality and continuous improvement are a daily activity of a good service and not just a duty followed
through external requirements.
0316
Degree of implementation of the Patient Safety Action Areas at hospital level in Andalusia.
R Burgos-Pol, D Nuñez-Garcia, JA Carrasco-Peralta
Andalusian Agency for Health Care Quality, Sevilla, Spain
Objective
To analyze the adaptation to the high-priority Patient Safety Action Areas of the World Health Organization (WHO)
through the Programme of Accreditation of Health Centres and Units (PACyU) in Andalusia.
Methods
Of the 12 high-priority Action Areas defined in the WHO World Alliance for Patient Safety (2008-2009), at least 5
requirements of obligatory fulfilment have been identified that agree totally with these lines through the PACyU.
Retrospective statistical study.
Key steps carried out: [1] Extraction and treatment of the records of the processes of accreditation of the health care units.
[2] Selection of the data associated with the 5 analyzed requirements. [3] Statistical treatment.
Timeframe: March 2010-Feb 2011.
Tools used: the records included in a specific online tool for the accreditation of the health units, called ME_jora C.
N = 87 accreditation projects
Study variables: fulfilment of the requirements.
Results
In the evaluated period, the percentage of fulfilment of these requirements in the external evaluation phase of PACyU was:
•
Risk management tools: 59.26%
•
Adverse events reporting system: 74.1%
•
Patient Identification: 96%
•
Availability of an alcohol station at the points of medical care: 99%
•
Availability of tools for the communication of the hand washing technique: 99%
Conclusions
There is a high degree of adaptation of the PACyU to certain high-priority WHO Patient Safety Action Areas, mainly in the
strategy of Hand Hygiene and in the identification of patients.
To a lesser extent, this adaptation is also found in the implementation and the adoption of validated risk management
tools.
0320
A survey on medication knowledge and experience of patients in Taiwan
Julia Hsu, Jie-Hui Chen, Ching-Feng Chiang, Lie-Jung Huang, Ian Chen
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District,New Taipei City, Taiwan
Objective:
To evaluate the knowledge and experience of general population, we performed a survey regarding ‘’the 5 core abilities
on correct medication.’’
Methods:
For adults and elementary school high grade students mainly, the survey was carried out by random selection nationwide,
computer-assisted telephone interviewing on correct medication knowledge, and the questionnaire designed was based
on the 5 abilities: ability 1 "clearly express the physical conditions "; ability 2 " read the labeling correctly"; ability 3
"knowing the medication method and timing clearly "; ability 4 "be your own body's master "and ability 5 " be friends with
your doctor and pharmacist", and further promoted the education on medication to the public through medical institutions
and local community units jointly. The questionnaire was divided into three parts, which included: medication knowledge,
medication experience and personal information. There were 1000 adults (20-70 years) and 2,766 students
questionnaires collected.
Results:
The surveyed population had “experience” (61.42% in adults, 59.8% in elementary school students) was lower than
"knowledge" (80.02% in adults, 61.4% in elementary school students) on the five core abilities of correct medication.
Comparison of the two groups for the five core abilities found that, although the performance of elementary school
students with "knowledge" of correct medication was lower than adults significantly (P<0.05), the difference between
"knowledge" (61.4%) and "experience" (59.8%) was smaller in students. Only 47.67% of population was familiar with a
family doctor or pharmacist who provides medication counseling.
In addition, in order to had further understanding whether the availability of family doctor or pharmacist to provide advice
make any differences on knowledge and experience, by cross-analysis between "family with familiar doctor or pharmacist
providing medication consultation" and the public correct medication knowledge and skills, the samples were excluded
with the answer of "Do not know" and people did not answer, the analysis found that families with familiar doctors or
pharmacists providing consultation, the knowledge and experience of the five core abilities in correct medication were
higher than those do not with familiar doctors or pharmacist providing consultation.
Group
adult
elementary school students
Knowledge/ experience
knowledge
experience
knowledge
with familiar doctor
/pharmacist or not
with
without
with
without
with
without
with
without
Ability1
74.6%
63.7%*
29.0%
24.5%
49.1%
44.5%
46.2%
42.7%
Ability2
86.0%
75.5%*
62.3%
47.6%*
66.2%
59.6%*
63.3%
57.2%*
Ability3
71.6%
65.6%*
-
-
53.3%
50.5%
-
-
Ability4
95.3%
92.8%
97.0%
94.8%
81.6%
80.5%
16.3%
15.5%
Ability5
91.8%
88.9%
87.2%
80.9%
73.6%
66.3%*
61.2%
17.8%*
experience
* p<0.05with vs. without familiar doctor/pharmacist.,
Conclusion:
Although adults have a higher understanding of correct medication than student, there was still a need to strengthen the
implement of the correct medication behaviour. Students showed more correct medication behaviors than adults,
therefore the correct medicine knowledge should be included into school education to make the correct medication rooted
and implemented at early ages. A better performance and medication knowledge for the families with familiar doctor or
pharmacist, therefore recommendation “be friends with your doctor and pharmacist " should be continually promoted and
thus promote the public on correct medication behavior.
0322
The Relationship Between Patient Safety Culture and Incident Report Rates in Taiwan
Chien-Ming Lo, Hsun-Hsiang Liao, Wui-Chiang Lee, Ian Chen
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District,New Taipei City, Taiwan
Objective:
To understand the correlation between patient safety culture (PSC) and incident reporting rates in Taiwan.
Methods:
The data were collected from the Taiwan Patient Safety Culture Survey (TPSCS) and patient-safety reporting survey in
2008. Respondents of the TPSCS were employees of healthcare institutions and tested with the Chinese version Safety
Attitude Questionnaire (SAQ) in 2008. The five aspects of SAQ were teamwork climate, safety climate, job satisfaction,
perception of management, and working conditions. In all cases, the range of scores is from 0 to 100, with higher scores
indicating a more positive response. To ensure data quality, all items with the same answer or a questionnaire containing
many missing data were considered to be invalid in the data cleaning process. Since 2003, the year when Taiwan PatientSafety Reporting System was founded, the persons responsible for incident reports have been asked to submit the
number of hospital incident reported and the total number of patient-stay days in their hospital. The patient safety incident
report rate was expressed as the number of hospital incident reported divided by total number of patient-stay days. To
understand the correlation between PSC and incident reporting rates on a hospital-basis, 4 groups were established
according to the SAQ score of each hospital from low to high and by using ANOVA (one-way analysis for variances) to
observe if there was any difference in the incident report rate among the 4 groups. The Pearson correlation analysis was
used to test the SAQ scores and patient safety incident report rates.
Results:
A total of 27,134 surveys of the SAQ were collected from 119 hospitals with a return rate of 73%. The average score was
th
th
th
68.2, the 25 percentile was 56.3, the 50 percentile was 68.0, and the 75 percentile was 81.9. The average incident
report rate was 0.47%, the minimum was 0.23% and the maximum was 3.58%. For those hospitals, whose SAQ scores
th
were lower than the 25 percentile, their average incident report rate was 0.29%; the hospitals with SAQ scores between
th
th
th
the 25 and 50 percentile had an average incident report rate of 0.41%;the hospitals with SAQ scores between the 50
th
th
and 75 percentile had an average incident report rate of 0.48%; the hospitals with SAQ scores higher than the 75
percentile had an average incident report rate of 0.69%. The incident report rates of the 4 groups, which were established
based on the SAQ scores, showed significant difference (p<0.05). The hospital’s SAQ scores was positively correlated
with the incident report rate (Pearson coefficient=0.20, p=0.03)
Figure 1. Association between Safety Attitude Questionnaire (SAQ) score and incident report rates
Conclusions:
This study demonstrated that the higher of SAQ score, the higher of the incident report rate in a hospital. The incident
report rate can be a proxy indicator of PSC. Hospital should try to improve safety climate which can enhance the intention
of medical staffs to report, and further increase the patient safety incident report rate.
0323
Analysis of inpatient suicides in health care institutions from Taiwan Patient Safety Reporting System
1
1
1
2
Hsiao-Jung Cheng , Hsun-Hsiang Liao , Cheng-Chung Fang , Chung-Liang Shih
1
2
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District,New Taipei City, Taiwan, Department of
Health, Executive Yuan, R.O.C.(TAIWAN), Taipei City, Taiwan
Objectives:
From the data of Taiwan Patient Safety Reporting System, we try to understand the situation of inpatient suicide and offer
recommendations for medical practice according to the analyzed results.
Methods:
Since 2003 Taiwan Joint Commission on Hospital Accreditation (TJCHA) had began planning to establish Taiwan Patient
Safety Reporting System (TPR), the system formally launched in 2005, which was an anonymous, voluntary and learning
purposed reporting system, the medical care provider from the institutions that accepted to take the system informing any
seen and heard unusual patient safety incidents, including near miss events. Data were collected from year 2005 to 2010
and 134,190 cases in total, which included 916 inpatient suicides. In this study, analysis of the place, time, and behavior
characteristics on the cases to understand the status of patient suicides, and according to the analysis results to offer
proposals to provide health care institutions.
Results:
In the 916 cases, inpatient suicide occurred mostly in general hospitals, a total of 623 (68.0%) cases, 229 (25.0%) cases
in psychiatric hospital, 15 (1.6%) cases in nursing home, 7 (0.8%) cases in psychiatric rehabilitation institutions, 5(0.5%)
cases in other health care institutions, and 37 cases were not filled by reporters. In these patient suicide cases, 62 (6.8%)
resulted in death, 140 (15.3%) resulted in very severe and severe harm, 395 (43.1%) resulted in moderate and minor
harm, 205 (22.4%) resulted with no harm, 75 (8.2%) were near miss, 31 (3.4%) were with a degree of injury that was not
able to determine, 8 (0.9%) cases were unknown. The cases were further differentiated between the division unit where
the suicidal patient stayed and the severity, and the results showed as the table below. Further analysis of 46 suicidal
deaths in non-psychiatric units, 37 were inpatients, 3 were outpatient, 3 were emergency patients, and 3 were unknown;
in suicidal death of inpatients, 22 were internal medicine patients, which took the biggest proportion, followed by 7 surgical
patients, and the other 3 were oncology patients.
Type of institution
Non-psychiatric units in
general hospital*
Psychiatric units in
general hospital
Psychiatric
hospital
Death
46
8
4
Very severe and severe harm
59
31
42
Under moderate harm
285
170
183
Total
390
209
229
cases by severity
P-value
<0.005
* : Distribution of suicidal cases’ severity in non-psychiatric units in general hospital is differ from the other 2 division
units, p-value <0.005
Conclusions:
According to the analysis on patient suicides from Taiwan Patient Safety Reporting system, the proportion on reported
cases and deaths of non-psychiatric unit in general hospitals is higher than that in psychiatric units and psychiatric
hospitals. Relative comparison with psychiatric unit on the strict access, goods and environmental control, the prevention
of patient commit suicides in general care unit was more difficult, showing that systematic conducts, such as working
processes and training were required for the general care providers to strengthen the ability of assessing the tendency of
suicidal patients and be able to transfer the patients.
0324
The use of surgical checklist in operating rooms in Taiwan
2
1
1
1
Shi-Ping Luh , Shiow-Ju Yeh , Hsun-Hsiang Liao , Ian Chen
1
2
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District,New Taipei City, Taiwan, St. Martin De
Porres Hospital, Chiayi City, Taiwan
Objective:
A site visiting program was used to survey the use of surgical checklist in operating rooms in Taiwan.
Methods:
50 hospitals in different size were selected for the site visiting. There were 7 large size, 24 middle size and 19 small size
th
th
hospitals visited from October 7 to November 5 in 2010. Task force was established by the TJCHA (Taiwan Joint
Commission on Hospital Accreditation) for the site visiting surveyors to collect data and to interview with the operation
team. There are four domains for the data collection, policy of implementing surgical safety, sign in before induction of
anaesthesia, time out before incision, sign out after operation. Consensus about site visiting was held with visit the
operating prepare room, operating room and recovering room in 2 hours. Data coding is done by two surveyors from
observation of actual performances and interview of related staffs. To validate the data findings was validated to develop
a tool kit in task force meetings.
Results:
There are 94% of surveyed hospitals using surgical checklist. Used wrist bracelet, for patient identification is 100%, by
face- to- face confirm 76%, or self- description 70%. Details of checklist implementation are shown in Table1.
Table 1
Implementation surgical checklist by hospital size
Items
Counseling clinics for anesthesia
Marking operation sites by surgeons
Airway assessment or aspiration risk before anesthesia
Risk of >500 ml blood loss
Introducing names, roles and capabilities of the team
members before incision
“Time-out” before incision has been performed more
commonly
“Debrief” after completion of operation
“Hand-off” between staffs of operating and recovery rooms
are well implemented
Committees about the operating safety held periodically
Monitoring for the improvement
*P<0.05 v.s. the other type of hospital size
Type of hospital size
Total(N=50)
Large
size(N=7)
100%*
86%
71%
86%
14%
Middle
size(N=24)
25%
67%
92%
88%
25%
Small
size(N=19)
16%
79%
89%
74%
5%
32%
74%
88%
82%
16%
100%
79%
53%
72%
14%
100%
42%*
96%
11%
58%*
26%
82%
100%
86%
88%
46%*
89%
26%*
90%
22%
However, introducing names, roles and capabilities of the team members before incision are only performed routinely in
16%. “Debrief” after completion of operation is performed for only 26%. Comparing with WHO international standards in
2009, there exist some discrepancies in Taiwan from cultural differences, and inter-institutional differences from different
sizes. In addition, the practical implementations of checklist to ensure surgical safety still leave some issues to be desired.
Thus, three large-scale workshops and lectures have been held. Many benchmark interventions, such as that to motivate
the surgical physician to participate actively, has been viewed and spread in Taiwan. Most hospitals hope to learn more
about the standard procedure by demo video that taken and shared by peers. It is very useful to show and present the
way how to do briefing, time out, debriefing by video in the team.
Conclusions:
An effective and feasible checklist is very important to improve surgical safety. Through the site visiting, surgical teams
can share with each other and empower themselves by realizing the cultural differences and hospital size characteristics.
From the findings, the tool kit with surgical checklist will be created and modified in the more suitable and feasible way.
0325
The experience of encouraging clinical workers to practice evidence-based medicine by a campaign in Taiwan
Yu-Lin Chen, Bi-Jiuan Wu, Hsun-Hsiang Liao, Ian Chen
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District, New Taipei City, Taiwan
Objective:
We performed a campaign to promote the use of Evidence-Based Medicine (EBM) in clinical situation, and the
effectiveness of this campaign was evaluated.
Methods:
In 2006, Taiwan Joint Commission on Hospital Accreditation (TJCHA) added a new campaign goal "EBM literature
review” in Healthcare Quality Improvement Campaign (HQIC), which had been promoted since 2000 in order to get
Taiwanese facilities’ attention to EBM. Campaign was held every year, and the candidates were medical workers, taking 3
people as a team and regulated that the team members must have different expertise. Campaign rating subjects adopted
"the 5 major steps in the implementation of EBM" by David Sackett, which included: ask an answerable question , search
for the best evidence, critically appraisal the evidence, application to solution of patient's clinical problem solving and
evaluate performance. An expert group was asked to create a clinical situation as the campaign examination question in
advance. On the day of the campaign, it was divided into three stages, the first stage: After the participating teams got the
situational questions, they should present in writing for at least 2 PICO (Patient or Problem, Intervention, Comparison and
Outcomes); the second stage: the teams picked up a PICO of their own choice to conduct a literature research, reading
and evidence collection and made presentation slides at the same time. Finally, each team had 10 minutes to briefly
present the results from the previous two stages, the judges made the rating scores. To assess the effectiveness of the
activities, a questionnaire survey (a questionnaire on each team) was carried out in 2009 and 2010 respectively, every
participating team was invited to make a self-assessment for the EBM skills learned after the competition, assessed
subjects included: level of understanding on EBM 5 major steps, literature research skills, literature comment reading
skills, the combination of EBM and clinical application, understanding the assessment on the effectiveness of EBM clinical
application, teamwork and team study, as well as presentation skills. A total of 78 questionnaires were collected in two
years, the response rate was 54.6%.
Results:
The results of questionnaire showed that the top three skills which the team learned the most in the campaign were: "
level of understanding on EBM 5 major steps" ,"enhancement of teamwork" and "enhancement of EBM literature research
skills"; analysis scores of the participating teams in 2009 ~ 2010 found that, among the five rating dimensions "PICO
quality and quantity" had the best scores, followed by "literature research"; and the subjects that need to be strengthened
the most was "from evidence to application", which included "to describe the effects of different clinical decision-making
on the quality of medical care" and "cost-effectiveness ".
From year 2006 to 2010, the number of participating teams（from 10 to 77 teams）increased year by year, and every
year there were new facilities participated. And the participating registration form showed that the rate of teams involved
in the hospital’s internal or regional campaigns increased from 22.5% to 56%, which indicated that to hold a national
campaign did successfully evoke hospitals to provide reward to promote the application of EBM.
Conclusions:
It has been five years since the campaign has been started to hold, from the observation that every year there are new
hospitals participated and the increasing number of participating groups, the effort input on EBM from facilities in Taiwan
can be seen, and the promotion of incentive on EBM from a campaign mechanism can be understood from the selfassessment questionnaires of participants, but the sustainability of the learning outcomes will be subject to further
evaluation and research.
0327
REDUCING ERRORS DERIVED FROM INPATIENT CHEMOTHERAPY PRESCRIPTION ORDERS BY UTILIZING
HOSPITAL INFORMATION COMMUNICATION SYSTEM
1
1
2
2
Ming-Hong Chen , Hui-Ti Sung , Yen-Yang Chen , Kun-Ming Rau
1
Department of Pharmacy, Chang Gung Memorial Hospital-Kaohsiung Medical Center & Chang Gung University College
2
of Medicine, Kaohsiung, Taiwan, Division of Hematology-Oncology, Department of Internal Medicine & Cancer Center,
Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan
Objective:
In order to promote the safety and effectiveness of chemotherapy for in-hospital patients, we established a real-time
monitoring and management system, which was linked to the Hospital Information System (HIS) and mobile-texting
technology.
Method:
Step 1. Establishing the e-system of chemotherapy prescription orders in Aug 2006.
Step 2. Establishing the e-system for chemotherapy medical services and error management in 2007:
When a questionable prescription or a wrong medication reconstruction occurs, the pharmacists must key-in an error
report and the cause of this error into the HIS. The HIS will analyze information, and submit results to each cancer group
and the chemotherapy pharmacy monthly . The chemotherapy pharmacy also needs to analyze and present relative
errors every two months in the chemotherapy safety council, in which the medical team will generate a consensus to
resolve each given error.
Step 3. Establishing the e-system for application and review of anticancer agents in June 2010:
3.1. Regularly updating and modifying chemotherapy prescriptions: Every cancer group sets up standard protocols and
prescription orders, all protocols and orders must fit evidence-based medicine.
3.2. Using HIS to assist the safety of prescription of anti-cancer agents: Warnings and restrictions could be given on the
dosage, route, cautions for administration, and contradictions for infusion solutions of drugs.
3.3. Establishing the confirmation system in HIS for prescriptions of anti-cancer agents: Prescription orders given by
residents and physician assistants will only be stored in the computer; orders cannot be printed out for administration until
they have been confirmed by attending physicians. Orders for target therapies and non-protocol chemotherapies are
asked to perform an on-line registration and must be checked by authorized Hematologists or medical Oncologists. Unapproved orders can still be reviewed by a committee within 48 hours.
Step 4. We used the Chi-Square Test and the Odds Ratio to compare the chemotherapy errors happened between 2006
and 2010, to see if there was significant decrease due to employing the chemotherapy safety monitoring and
management system. The P value is defined as below 0.05 for statistical significance.
Results:
Chemotherapy prescription orders e-system reached 100% completion in 2007. There were 2,526 cases applied for
chemotherapy administration from June to December 2010. Of these cases, 870 required to be reviewed, and 21 of them
were rejected. 13(1.5%) of these rejected cases were really rejected after the committee. Amongst the chemotherapy
applications requiring to be reviewed by attending physicians, 91.6% could be completed within 48 hours. For those
requiring committee reviews, 96.1% could be completed within 48 hours. There were 16,801 chemotherapy prescription
orders administered in the hospital in 2006, with 78 (0.46%) errors happened amongst. 0.02% error cases (3/15,584)
2
were discovered for 2010. There is significant decrease in the error cases (x = 64.17, df= 1, P= 1.14E-15), and a 95.85%
decrease in the prescription error risk (odds ratio= 0.04, 95% confidence interval: 0.01~0.13, P= 0.03).
Conclusion:
The Information Communication System established by the hospital for monitoring chemotherapy safety and error
management could decrease the number of inpatient chemotherapy prescription order errors. It could also provide
patients with safer and more effective chemotherapy services within a reasonable timeline.
0329
Promote breastfeeding by the certification program on Baby-friendly hospitals and clinics
Hui-Yu Li, Su-Hua Lee, Lie-Jung Huang, Ian Chen
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District, New Taipei City, Taiwan
Objective:
By external audit and peer competition to encourage hospitals and clinics to provide a better breastfeeding environment
and hence to increase the breastfeeding rate.
Methods:
In view of the breastfeeding rate in Taiwan was only 5.8% in 1996, which is lower than that of 66% in Denmark, 41% in
Japan, and 23 ~ 44% in United Kingdom and United States; therefore, enhancing the breastfeeding rate in Taiwan has
became an important task in public health.
We took the experience of Baby-Friendly Hospital Initiative( BFHI) that WHO and United Nations Children's Fund
(UNICEF) jointly proposed as the reference and invited experts, scholars, health authorities and peer to compose a
project team to develop a certification program in Taiwan; hospitals and clinics that provide obstetric service could apply
on a “voluntary basis” and adopted " On-site inspection " as the core of the system, the process was carried out in the
following manner:
1. The certification is proceeded through interviews, medical record review, annual statistical analysis and medical related
work.
2. The surveyors interviewed the obstetricians, pediatricians, nurses and mothers, and the interviewing covers the
maternity ward, nursery and out-patient units.
3. We also performed a questionnaire to the hospitals/clinics and surveyors in order to evaluate the effectiveness.
Results:
1. The coverage of hospitals and clinics participated in “Baby-friendly Hospital Initiative Certification” was based on the
number of childbirth reported from Bureau of National Health in 2010, and the total number of certified hospitals and
clinics was 144. From the 407 hospitals that had birth registered in the record of notification, a total of 122,472 cases of
live births in 2010. In terms of the coverage of certified hospitals, the 144 hospitals and clinics accounted for 35.4% out
of the total number of hospitals and clinics nationwide; as to calculate the percentage of total number of births, the
result was 67.2%, which was higher than the 53.9% in 2009, increased by 13.3%, the certification pass rate has been
increasing according to results, number from 94 (88 hospitals, 6 clinics) in 2007 increased to 144 (121 hospitals,
23clinics) in 2010, substantially increased by 56.95%, as shown in Table 1.
2. In 2010, the average “breastfeeding only” rate was 41.86% during hospital stay, apparently increased over previous
years. Bureau of Health Promotion study showed that in 2010 the average breastfeeding duration of a baby in a Babyfriendly hospital/clinic was 3.3 months, which was higher than the 2.4 months for the one in a non-baby-friendly
hospital/clinic, the statistic confirmed that the breastfeeding rate of a baby given birth in a Baby-friendly hospital/clinic
was significantly higher than that in a non-baby-friendly hospital/clinic.
3. In terms of the implementation effectiveness in the certification process, a survey was carried out by giving
questionnaire to the hospitals and clinics and surveyors to analyze the administrative operations, the process of the
work, satisfaction for the overall process and so on; 97.3% of the hospitals and clinics and surveyors showed a positive
identification that the certification system provided real benefits to improve the breastfeeding rate.
4. Established follow-up visits from time to time to maintain the Baby-friendly hospitals and clinics for the quality in
obstetric services and assist those hospitals and clinics that willing to apply for Baby-friendly certification to pass the
certification, in order to achieve the result in increasing the breastfeeding rate.
Conclusions:
1. The resulting certification pass rate has been increasing year by year, as well as the breastfeeding rate, showing that
the policy supporting in breastfeeding, through a certification system, played an important role in successful promotion
for mothers to breastfeed.
2. The breastfeeding rate of a certified hospitals and clinics was higher than non-certificated hospitals and clinics, showing
the important influence of the certification system in initiative for hospitals and clinics to create a breastfeeding
environment.
Table 1. The coverage of the applying Baby-friendly hospitals and clinics certification
Number of certified
Birth in the certified
hospital/clinic
hospital/clinic
National Total
No. of
Year
No. of
No. of birth
hospital
%
No. of birth %
hospital
2007 461
95400
94
20.4
45228
47.4
2008 447
78251
94
21.0
36202
46.3
2009 433
140650
113
26.1
75852
53.9
2010 407
122472
144
35.4
82277
67.2
0330
Hospital accreditation and its impact on patient satisfaction with hospital-based care
Ki Fung Kelvin Lam, Frankie Lau, Josephine Ngai, Janice Mary Johnston
The University of Hong Kong, Hong Kong
Background
Hospital accreditation is increasingly adopted to meet the rising expectations of improved health care service standards.
However there is little empirical evidence to support the assumption that hospital accreditation leads to improvement in
patient satisfaction with the quality of in-patient care.
Study Setting and Methods
This study examines comparatively patient satisfaction levels pre and post the pilot hospital accreditation in Hong Kong. A
cross-sectional survey of patient satisfaction was adopted to establish at baseline, prior to the hospital accreditation
survey in Queen Mary Hospital, patient perceptions of health care quality. Adult patients admitted to hospital (18-80 years
of age, minimum length of stay of 2 days) were invited to complete the Picker Patient Experience (PPE 15) telephone
survey one-week post discharge. The PPE-15 elicited patient feedback regarding seven aspects of health care
performance and quality of care including: information and education, coordination of care, physical comfort, emotional
support, respect for patient preferences, involvement of family and friends and continuity and transition. Each item is
dichotomized as to the indication of a problem or not. Simple additive scoring was used to compute the PPE-15 summary
scores overall and by factor. The survey also collected patient-related socio-demographic, health risk behaviour and selfperceived health information. Per patient length of stay and number of admissions in the past 12 months were obtained
from the Hospital Authority discharge data base. A second cross-sectional survey was undertaken 3 months post the
main accreditation survey. For each survey, descriptive analysis and multivariable regression modelling will be used to
assess the effect of individual characteristics on PPE-15 scores. Pre and post test PPE-15 scores were compared (t-test
and the Wilcoxon-Mann-Whitney test) to assess the impact of accreditation on patient satisfaction.
Results
At baseline, post discharge telephone interviews were successfully completed by 900 of 1133 patients (84.3% response
rate). Although 80.7% of the patients were non alcohol drinkers and 90.9% non smokers, 68.4% reported their selfperceived health to be poor. Overall patients scored their last inpatient admission 41.1 (Cl: 39.6-42.6) (Range 0 - 100, the
lower the score, the better the patient experience and or satisfaction). Among the PPE-15 items, the highest score (65.6)
for “Did you want to be more involved in decisions made about your care and treatment?” and lowest score (19.0) for “Did
doctors talk in front of you as if you weren’t there?” Patients of primary education or below reported a lower score (35.4)
than those of secondary (42.5) or tertiary (46.3) education level. Patients with “Fair to Poor” self-perceived health (43.8)
scored their last hospitalization higher than those with “Excellent to Good” (35.5). Patients with a length of stay above the
mean length of stay were significantly associated (p= 0.045) with lower problematic scores (OR 0.75, CI 0.56-0.99). After
adjustment for outliers from the hospital database, these patients reported a yearly mean of 3.12 hospitalisations (Range
1 – 12) with a mean per episode length of stay of 5.10 days (Range 2 - 17). Post accreditation PPE-15 comparative
analysis will assess the potential impact of hospital accreditation on aspects of patient satisfaction.
Conclusions
The overall summary score was marginally lower than the territory-wide study previously reported in Hong Kong (effect
size= 0.06). Pre accreditation, patients were most dissatisfied with uninformed decisions about care and treatment. While
years of education, was a predictor for lower levels of patient satisfaction in the literature, the reverse was observed in
Hong Kong. This is perhaps explained by expectancy theory. The PPE-15 score highlights areas of quality improvement
potentially due to the hospital accreditation exercise. However further study is needed to confirm possible causality.
0332
To streamline the process of escorting Castle Peak Hospital in-patients with acute physical problems to general
hospital for assessment
1
3
2
2
Paulina Chow , Abdul Karim Bin Kitchell , Elvis Mak , Chi Sing Wong
1
2
3
Castle Peak Hospital, Hong Kong, Tuen Mun Hospital, Hong Kong, North District Hospital, Hong Kong
Introduction
Castle Peak Hospital (CPH) in-patient who suffered from acute physical problem requiring general hospital support would
be escorted by a psychiatric nurse to Tuen Mun Hospital (TMH) Accident & Emergency Department (AED) for
assessment and treatment. Due to the high service demand at TMH AED, patients took an average of 3.6 hours (216
minutes) to complete the assessment process. This resulted in patients’ suffering. In addition, the CPH nurses were
occupied in the entire escort process, and this further tightened the tense nursing manpower in CPH.
Objective
To streamline the process of escorting CPH in-patients with acute physical problems to TMH for assessment and
treatment.
Methods
The escort process was streamlined through the following strategies implemented on 21 June 2010:
1.
To establish the direct admission right of the CPH psychiatrists to admit CPH in-patients with selected types of acute
physical problems directly to TMH Emergency Medicine Ward for treatment, bypassing the lengthy process of
assessment at TMH AED.
2.
To encourage the CPH nurses to hand-over patients with low risk of violence, self-harm and abscondence to TMH
AED nurses, which minimises the duplication of nursing care on the same patient in the assessment process, and
enables the CPH nurses to return to CPH to resume their hospital-based clinical duty at the earliest possible time.
3.
To allow suitable CPH patients to return by taxi from TMH AED to CPH escorted by CPH nurses after assessment,
thus reduces the time spent in waiting for Non-Emergency Ambulance Transfer Service (NEATS) in the return trip.
Results
A total of 68 CPH in-patients who were transferred to TMH for acute physical problems were surveyed in the 50 days’
period since the implementation of the improvement strategies. 22 were directly admitted to TMH EMW, 9 were handedover by CPH nurses to TMH AED nurses, 5 took taxi on their return to CPH.
Improvement strategy
Pre-intervention measurement
Post-intervention measurement
1. Direct admission
Total escort time through AED:
Total escort time to EMW: 42.6 mins (35-53 mins, SD
5.7); 80% reduction
n= 22
2. Hand-over
n= 9
3. Return by taxi
n= 5
Combination of strategies
1, 2, 3
216 mins
Total escort time through AED:
216 mins
Average waiting time for NEATS:
49.3 mins
Average escort time:
216 mins
Total escort time through AED: 90.9 mins (60-135 mins,
SD 21.6); 58% reduction
Average waiting time for taxi: 6.2 mins (4-10 mins, SD
2.4); 89% reduction
Average escort time:124.5 mins (35-308 mins, SD 61.7);
42% reduction
Conclusion
A 42% shortening of the escort process was achieved through the collaboration between CPH and TMH. Patients could
be settled in the ward for treatment at an earlier time. CPH nurses could be released from a shorter escort process and
resume their usual clinical duty promptly. The improvement resulted in quality improvement in patient care, and
effectiveness enhancement in nursing resources in CPH.
0333
Promote caring culture for health workers in hospitals in Taiwan
Shu-Mei Lin, Hsun-Hsiang Liao, Cheng-Chung Fang
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District, New Taipei City, Taiwan
Objective
To concern the needs and pressure of medical staffs, we build caring culture in medical institutions by using a systematic
curriculum plan, participating hospital senior managers, and sharing experiences at the workshops.
Methods
We set up topics and used modular courses, and through the module teaching to the hospital senior mangers and sharing
experiences at the workshops, a feasible practical approach or strategy was produced.
1. Planning the curriculum
A project team established course objectives, then designed a series of related modules for hospital senior managers.
Firstly, the status of the caring was figured out; looked into the ways of coping with " status of caring", started from "self
care" of each individual and then extended to "team care" to help team members; further into "organization care" of
medical institutions.
2. Planning the workshop:
The caring program was extended and carried out as the workshop manner, giving sufficient time to discuss and
further gave an output of feasible measures, which was able to apply practically on the medical institutions where those
senior managers were involved.
3. Measuring indicators were the course satisfaction and the ratio of medical institutions that participated "systematic
caring program”.
Results
1. Survey analysis on modular courses and workshops satisfaction:
(1) Since June 2010 to December 2010, the modular courses and the workshops were taken place 5 times for each
respectively.
(2) A total of 9 hospitals, which included 5 public hospitals (55.6%), 4 private hospitals (44.4%), among them there
were 3 large hospitals (33.3%), and 6 medium-sized hospitals (66.7%).
(3) A total of 149 participants, including 40% of them were senior managers.
(4) The overall satisfaction on modular courses and workshops was 89.3%.
2. Systematic caring program in medical institution:
(1) A survey of the participating medical institutions was carried out in December 2010, 3 (33% of the participating
medical institutions) had established the caring system.(2) Among the 3 medical institutions that had established the
"systematic caring program", 2 of which were private hospitals, 1 was public hospital, and all of them were large
hospitals.
Conclusion
We have established a program to help health care organizations to build caring culture. This program seemed
satisfactory from the view of participants of the medical institutions. Further studies about the caring climate in the
institutions should be measured to prove the effectiveness of this program.
0334
Factors Related to Health Outcome After Unplanned Extubation in a Nationwide Incident Reporting System
1
1
1
2
Cheng-Chung Fang , Hsun-Hsiang Liao , Ian Chen , Chung-Liang Shih
1
2
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District, New Taipei City, Taiwan, Department of
Health, Executive Yuan, R.O.C.(TAIWAN), Taipei City, Taiwan
Objectives:
To examine the risk factors of poor health outcome after unplanned extubation (UE) in a nationwide incident reporting
system.
Method:
An incident reporting system on unplanned extubation was established in Taiwan by the Taiwan Joint Commission on
Hospital Accreditation (TJCHA) in 2005 as part of its goal to establish and create a patient safety environment in all health
care setting in Taiwan. This anonymous reporting system encouraged all health care personals to report all incidence of
UE in their work setting. Data was collected from January 2005 to December 2009. Multivariate logistic regression model
was used to predict the health outcome of the incidents using SAS 9.2.
Results:
There were 4108 incident reports of UE collected in the system, 3440 incidents resulted in minor injuries and 216
incidents had major injuries or death. There were 452 missing data. Factors related to poor health outcome are a
caregiver present at the time of incident (OR: 1.57), accidental extubation (OR: 1.68), subsequent reintubation (OR: 3.61),
and conscious impairment (OR: 1.43). If the incident happened in the surgical subunits (OR: 0.39) or in special care units
(OR: 0.58) the outcome showed a lesser degree of injury. After adjusting to the other variables, subsequent reintubation,
presence of a caregiver, and surgical subunits showed statistical significance (p<0.0001,p=0.02, p=0.003 respectively). It
is important to note that incidents received subsequent reintubation had twice as higher risk to have a poor health
outcome compared to those who were not reintubated (OR: 3.24).
Conclusion:
UE is considered as an adverse event in patient care and is a direct reflection of patient safety in a health care setting.
Many of these incidences increase patients’ mortality and morbidity thus resulting in increasing cost in patient care.
1. Subsequent reintubation is an important risk factor in the determination of outcome in UE. Patients should be
observed closely after UE especially those that are reintubated.
2. A caregiver present during the incident increased a 43% chance of poor outcome. Caretakers should take caution in
caring patients with endotracheal devices especially when assisting physical activity on patient. They should be
trained in standard of care when UE occurs so that they may respond accordingly.
3. Incidents that happened in the surgical subunits had a 54% lesser chance of poorer health outcome. Patients in
surgical subunits should be assessed for early extubation so that UE can be avoid.
Table 1: Factors related with health outcome after UE using univariate logistic regression
Variable
Case (n)
OR
95%CI
Adult
Sex (Male)
Caregiver Present*
Accidental Extubation*
Reintubation*
Consciousness Impaired*
Anxious/Agitated
Lethargic/Comatose
Subunits
Surgical ICU*
Medical ICU
Special Care Unit
ED
ICU/RCW/Dialysis/OR*
Sedation Used
Restraint Used
Physical Activity
3550
2706
1048
656
1789
1.45
0.81
1.57
1.68
3.61
0.59 ~ 3.59
0.60 ~ 1.08
1.17 ~ 2.10
1.21 ~ 2336
2.55 ~ 5.11
1018
264
1.43
1.69
1.05 ~ 1.95
1.04 ~ 2.73
683
2229
0.39
0.83
0.24 ~ 0.63
0.54 ~ 1.27
65
3139
626
2547
865
1.43
0.58
1.20
1.23
1.1
0.62 ~ 3.27
0.43 ~ 0.78
0.83 ~ 1.73
0.91 ~ 1.66
0.79 ~ 1.54
*p<0.05; ICU: Intensive Care Unit, OR: Operation Room, ED: Emergency Department, CI: Confidence Interval
0335
An Project of Improving An Explanation before Gastrointestinal Endoscopy for Health Examiners
Pei-Shin Lee, Cheng-Yen Chiang, Tsae-Fen Lee, Tzu-Shin Huang
Taoyuan Chang-Gung Memorial Hospital, Taoyuan, Taiwan
Objective: The aim was to promote satisfaction levels among health examiners toward an explanation before
gastrointestinal endoscopy and to reduce anxiety levels for health examiners smoothly undergoing gastrointestinal
endoscopy.
Methods: A team was formed for conducting this improving project. A self-structured satisfaction scale was designed to
assess the causes of dissatisfaction and the satisfaction levels among health examiners receiving an explanation before
gastrointestinal endoscopy. A cross-sectional survey was completed from October 1, 2010 to October 31, 2010 (N = 949)
with a response rate of 100%. After analyzing the causes of dissatisfaction, some strategies were adopted to enhance
satisfaction levels by reviewing literature and discussing with the gastroenterologists. These strategies included: 1)
providing an explanation before gastrointestinal endocopy and executed gastrointestinal endoscopy by same
gastroenterologists for each team with limited health examiners (N = 6); 2) defining separated locations for each team in
order to reduce mutual interference during explanation of gastroenterologists (N = 3 ~ 4); 3) designing a standardized
teaching module as a reference for gastroenterologists to provide an explanation before gastrointestinal endoscopy; and 4)
designing four posters for the health examiners to understand the whole procedure of gastrointestinal endoscopy. After
one month, the second survey was conducted for evaluating the effect of improving strategies between December 1, 2010
and December 31, 2010 (N = 964).
Results: The causes of dissatisfaction consisted of 1) too noisy environment and no isolated locations for health
examiners to listen explanation of gastroenterologists; 2) different teaching contents provided by diverse
gastroenterologists; 3) no standardized teaching module for providing explanation by gastroenterologists. The satisfaction
level was increased from 63.7% to 96.8% after completing the improving project.
Conclusions: This project effectively enhances satisfaction levels and reduces anxious levels among health examiners
toward an explanation before gastrointestinal endoscopy. Likewise, the project successfully promotes the service quality
of the health centre. Thus, provision of customer-centre service is a very important perspective for health centres. These
strategies can be a reference for other health centres to increase the quality of service.
0336
Clean Hearts- Keeping Little Hearts Infection Free
David Winlaw, Gabrielle O'Grady, Karen Leclair, Elizabeth Harnett
The Children's Hospital at Westmead, Sydney, Australia
Objective:
To reduce the Surgical Site Infection(SSI) rate in the paediatric cardiac surgical patient from 2.9% to zero%.
Methods:
A range of stakeholders, including anaesthetists, cardiac surgeons and nursing staff were engaged to participate in the
project. Extensive consultation was continually sought for expert guidance and advice from Microbiology and Pharmacy.
External laboratories, GPs and patient families were also consulted in relation to the MRSA screening processes. The
Project Team met with stakeholders to review the current practice. A literature review was performed to identify the
evidence to practice gap. Lessons from a similar project recently completed in Neurosurgery were reviewed when
developing implementation strategies.
A review of the medical literature was performed and identified that the following care components can help to reduce the
incidence of SSI:
Appropriate use of prophylactic antibiotics: A prophylactic antibiotic regime was developed by Infectious Diseases and
Microbiology.
Early detection and treatment preoperatively of patients with MRSA or Staphylococcus aureus: A patient friendly system
was developed in consultation with the stakeholders to ensure timely screening and treatment.
Post-discharge wound surveillance: A process was implemented for a follow up phone call, allowing early detection and
treatment of potential wound breakdowns and infections.
The agreed components were combined as a bundle of care. This approach works on the knowledge that when multiple
evidence-based interventions are ‘bundled’, the reduction in SSI incidence is likely to exceed that which could be
produced by any single component in isolation. An evidence-based protocol checklist was developed. This was placed
into each patient’s notes pre-operatively. On discharge, the information is entered into a database to monitor process and
outcome measures. Any potential SSIs are reviewed by the team.
Results:
In the baseline period, the SSI rate in children admitted for cardiac surgery was 2.9 %. Following implementation of
interventions, the incidence of SSI has reduced to 1.3% (p=0.03). 985 patients were treated using the agreed protocol by
the end of December 2010. MRSA screening showed 20% of these patients had a positive MRSA or staphylococcal
colonisation and received appropriate pre-operative treatment.
Management of a SSI in paediatric cardiothoracic patients can involve treatment with IV antibiotics and possible returns to
theatre. The flow on benefits of the project revealed a reduction in returns to theatre from 3.6% to 1.7% (p=0.05) and a
reduction in days spent to treat SSIs with IV antibiotics from 57 days/quarter in the baseline period to 20 days/quarter [a
reduction of 64% (p<0.01)].Based on the estimated cost of managing a deep sternal infection and compared with the
2.9% baseline infection rate, this project is potentially saving over $250 000 per year.
Conclusions:
Through this project we realised that: Strong clinical leadership is essential to drive change, evidence based bundle of
care approach is effective in achieving desired outcomes and outcome data helps to engage the clinicians.
This initiative can be replicated to any surgical speciality to improve the patient experience, save money and reduce
potential of SSI’s.
0337
Exploration of Reasons for New Nursing Personnel for Leaving Employment
CHIU-YA KOU
Chang Gung Memorial Hospital, Chia Yi, Taiwan
1. Research Background and Motives:
The development of medical care in Taiwan demonstrates an increase in the need for human resources in nursing. At
present, there is insufficient supply in nursing human resources. With an increase of the consumption consciousness, the
public also has increasingly higher demands for medical care. Nursing work has become more complex and busy, with a
heavy workload, and as a corollary, the attrition rate of new personnel during the trial and training period has also
increased. It was estimated that in a teaching hospital in central-southern Taiwan, the total turnover rate in 2010 was
29.3%, of which new personnel turnover rate was as high as 53.8%, which demonstrates the problem of serious attrition
of nursing human resources. Because the hospital is located in a remote area in the south, it is difficult to recruit nursing
personnel. Facing an ever-increasing turnover rate of new personnel, it has caused serious attrition of nursing human
resources. An overview of domestic and foreign literature shows that nursing human resources significantly influences the
risk of death of patients and the safety of patients in their hospital stays; this elicited this study’s motivations for
exploration.
2. Research Purposes:
To explore the reasons relating to new nursing personnel turnover, engage in analysis to resolve or lower turnover rates
for new nursing personnel.
3. Research Method:
After accounting, it was found that in 2010 there were 320 new personnel, and 172 left employment, with a turnover rate
of 53.8%. This study focused on the 172 of those who left employment for a cross-section research design, with a semistructural research questionnaire to investigate and analyze reasons for new personnel turnover.
4. Research Results:
The results showed that the reason for turnover of most new personnel was due to failure to adapt, with 107 people
(62.2%). Other reasons were in the order of: family factors with 27 people (15.7%), health reasons with 14 people (8.1%),
other reasons at 11 people (6.4%), other jobs with 10 people (5.8%), higher education with 2 people (1.2%), and other
industries with 1 person (0.6%).
5. Application in nursing:
Regarding the most primary reason for turnover of new personnel, counseling strategies for clinical teachers were
established, the department directors strengthened their humane care for employees, new personnel symposia were
regularly held, new slogans for changing shifts were created, the shift-changing procedures were simplified, and individual
personnel problems of poor adaptation were treated and resolved in a timely manner, in order to enhance retention rate
for new personnel.
0338
Oral Health Education for Residential Aged Care Facilities Carers
Natalie Oprea, Shirley Fong-Yang, Ranbeer Kaur, Kam Wa Sinn
Special Care dentistry Department, Sydney Dental Hospital, Surry Hills, New South Wales, Australia
Objective: To improve oral health awareness and its corresponding improved oral care by nurses for residents in
residential aged care facilities (RACF), thus preventing serious exacerbation of dental disease and medical conditions.
Methods: The Special Care Dentistry Department (SCD) of Sydney Dental Hospital has identified a need for more
comprehensive education for nurses working in Aged Care. A baseline survey of oral hygiene condition of residents was
conducted by SCD staff in 2002; the result shows a high rate of 54% of residents have very poor oral/denture care.
This can result in increased rate of tooth decay, gum disease, fungal infections, and other associated problems such as
pain, swallowing difficulties, speech impairment, eating/chewing difficulties, poor nutrition, etc.
A series of factors were identified as causing impaired oral hygiene care. Amongst them is minimal training in the nursing
curriculum on oral care. More emphasis is needed on the awareness and importance of dental health links to general
health, different shift hours among nurses, fast turnover of nursing staff, limited availability or out of date educational
materials.
With the awareness of these problems, the SCD department set out to address these factors. An intensive educational
support program was initiated. The SCD department staff developed a means of effective communication with the
managers of RACF in order to convey the importance of oral care to the general care for their clients.
In order to support their educational needs:
•
SCD Outreach Service dentists held in-service education sessions for nurses through appointments with the nursing
managers/nurse educator of the facility for all their nursing staff after residents had been examined.
•
An oral health DVD was created by our department so night shift staff would be able to avail the information in their
own time and a starting oral health education folder was created for Aged Care staff.
•
A series of formal intensive half day seminars and workshops were held twice a year at the Sydney Dental Hospital
lecture theatre for RACF Managers/Nurse Educators covering a wide range of relevant topics to oral health.
To address the curriculum on oral health education, SCD Head of Department conducted meetings with NSW Nursing
College and gave lectures to undergraduate nurses. Regular hands-on training sessions are also organized by SCD
department to designated nurse educator/s in each RACF willing to improve their performance in oral hygiene care.
Results: Oral/denture hygiene care has improved significantly from 2004 after this educational support program. Now
70% of people living in RACF covered by us have good oral hygiene care.
Pre and post educational survey questions were given to nurses. Pre-education survey shows approximately 50% of
nurses have difficulty in caring for oral and denture hygiene especially when patients are resistant to care such as
dementia patients. Post education results show increased knowledge and confidence by approximately 40% of which
93% of respondents would say they have improved their knowledge and confidence; 89% say they are able to better
recognize abnormalities in the mouth and teeth and so be able to alert their managers for further action and referral for
treatment as needed.
Conclusions: RACFs are now aware of a greater emphasis on oral care of residents. The accreditation bodies are
gradually implementing greater emphasis on dental care, which would include an assessment of adequate training
program of its nurses on oral care. The support of a specialist department for special needs patients such as SCD
towards the educational needs of the RACF is a vital factor in the progress of this oral health awareness program.
0339
A case control study for quality care of patients with NSTI
CHAN P.M., MAN N.W., TSANG K.K., LO C.Y.
HOSPITAL AUTHORITY, HONG KONG, China
Introduction
Necrotizing fasciitis are highly lethal types of bacterial infections that cause rapid tissue necrosis. Early identification and
prompt surgical treatments can decrease the related mortality and disability. Up-to-now, no one single method could be
concluded as the gold standard for diagnosing necrotizing soft tissue infection (NSTI) apart from operative diagnosis.
Transformations in diagnostic concerns as well as varieties in disease manifestations post great challenges to
professionals regarding appropriate disease treatments and nursing management.
Methodology
Hospital notes of all patients diagnosed NSTI and patients diagnosed “cellulitis” required “debridement” were reviewed in
a district hospital from the period of 2009 to 2010. Data on etiology, admission signs and symptoms, as well as laboratory
findings were collected in order to investigate any predictive variables for prompt diagnosis.
Result
24 patients were diagnosed NSTI and 64 patients were included as the “cellulitis group” for comparison. In the NSTI
group, mortality rate was 25%. The average numbers of operations performed was 3.2 per patient. 42% required ICU care
and 29% of them had amputation performed. Laboratory Risk Score for diagnosing NSTI was compared between groups.
Result showed that the mean score of NSTI group was significant higher than that of control group (p=0.014). When
investigating the accuracy and appropriateness of this test, the negative predictive value was around 82%, which
indicated a better prediction of not having NSTI with low Laboratory Risk Score. However, positive predictive value of was
41% only. In order to investigate the predictive valuables for diagnosing NSTI, logistic regression analysis was performed.
The results showed that “blister” (p=0.008), “hypotension” (p=0.039) and “erythema” (p=0.035) were correlated with NSTI
significantly. Their odd ratios with 95% confidence intervals were 11.80 (2.84, 49.03), 6.44 (1.46, 28.41) and 0.36 (0.09,
1.38) respectively.
Conclusion
NSTI was not a rare health problem and critical outcomes could be resulted. In this study, specific nursing roles are
highlighted including early disease recognition, critical nursing care, wound management, psychological and rehabilitation
care. Since the mortality and morbidity were high for NSTI, it was important to improve the patient’s safety and quality of
care by increasing alertness on clinical signs. Nurses need to observe for any blister formation and hypotension. Besides,
nurse should alert when the laboratory findings showing high laboratory risk score. Although it may be false positive,
closely monitor for NSTI is necessary unless there is proven of true negative.
0341
Assessment of CT dosage as a measure of service performance and patient safety: results in paediatric group
and lessons learnt.
Peter Yu, Andrea Au-Yeung, Joyce Hui
United Christian Hospital, Hong Kong
OBJECTIVE:
To audit the dose of CT examinations performed in the paediatric age group as a measure of service performance and
patient safety.
METHODS:
This is a retrospective review of all CT studies performed on patients 16 years or younger between the period 01/10/2010
and 31/12/2010. For the purpose of our study, the most commonly performed type of examination will be identified and
further reviewed. Patient demographic data, indication, CTDIvol and DLP for each case was recorded. Subgroup analysis
rd
(age <1, age 1-5, age 6-10, age 11-16) with mean, standard deviation, 3 quartile was performed and results compared
with international standards. Those cases exceeding the DRL or two standard deviations from our subgroup mean were
identified and individually reviewed for possible ways of improvement.
RESULTS:
Total of 190 CT examinations were performed with the far majority being non-contrast CT brain (n=145, 76%). The rest
were contrast CT brain (n=5, 2.6%) and CT of other body parts (n=40, 21%).
Within our largest group, i.e. non-contrast CT brain, the most common indication was seizure (n=44, 31%), followed by
head injury (n=32, 22%). There were 26 patients in the <1 age group, 48 patients in the 1-5 age group, 27 patients in the
rd
6-10 age group and 44 patients in the 11-16 age group. Their respective mean ± standard deviation and 3 quartile
results for CTDIvol for each age group were: 17.1 ± 1.2mGy and 18mGy, 21.6 ± 3.5mGy and 24mGy, 20.5 ± 4.0mGy and
rd
22mGy, 24.3mGy ± 6.7mGy and 27mGy. Their respective mean ± standard deviation and 3 quartile results for DLP for
each age group were: 214.7 ± 64.8mGycm and 229mGycm, 341.3 ± 158.5mGycm and 342mGycm, 318.2 ± 146.5mGycm
and 317mGycm, 354.5 ± 115.3mGycm and 383mGycm.
1
rd
Taking results from a multicentre study from Belgium as reference, our 3 quartile CTDIvol and DLP results for all age
2
groups were lower. Taking DRLs from a study from UK as reference, only 6 of our DLPs exceeded the reference level.
Detailed analysis of these cases showed that 5 had more than one sets of CT performed which was the reason for
exceeding DRL. Multiple sets were performed as a result of motion artefact which rendered the examination not
interpretable. Discounting these, there was only one case where the DLP exceeded the reference level. Unfortunately,
patient record for this case was not available for detailed review.
CONCLUSIONS:
Non-contrast brain was the most commonly performed CT examination in the paediatric age group. Our audit of dose,
using CTDIvol and DLP as measures, compare well with international standards. There were only six cases where DLP
exceeded the DRL. Five of these were due to multiple sets of CT being obtained as a result of motion artefact. Our results
highlighted the importance of adequate sedation in the paediatric age group.
REFERENCES:
1. CT paediatric doses in Belgium: a multi-centre study. Results from a dosimetry audit in 2007-2009.
www.fanc.fgov.be/CWS/GED/pop_View.aspx?LG=1&ID=2449
2. Reference doses for paediatric computed tomography. P.C. Shrimpton and B.F. Wall. Radiation Protection Dosimetry
Vol.90. Nos 1-2, pp.249-252 (2000)
0342
Streamlining UTIs
ANNA ROZARIO, AHMED JAMAL, ELIZABETH HARNETT
THE CHILDREN'S HOSPITAL AT WESTMEAD, SYDNEY, Australia
Objective:
To improve the journey of patients presenting to the Emergency Department with a Typical Urinary Tract Infection, whilst
at the same time improving overall patient flow and access for the Organisation.
Methods:
Impetus for the project was the increased demand on the organisation’s Tertiary Level inpatient services and new
evidence suggesting that management and treatment of children with a Typical UTI could be provided within a community
or primary setting.
The Streamlining UTIs Project followed the Clinical Redesign program methodology, a NSW State-wide Health initiative
that applies the principles and practice of process redesign to healthcare. Clinical Redesign Units conduct process
improvement projects aimed at achieving better outcomes for patients, their families and the staff who treat them. The key
aspects of Clinical Redesign methodology are, Initiation Start-Up, Diagnostics, Solution Design, Implementation Planning,
Implementation, Evaluation, Sustainability and Knowledge Sharing.
The Streamlining UTIs project engaged internal and external stakeholders to
•
develop and implement evidence based change of clinical practice with Guidelines and a Planned Model of Care
to support these changes
•
develop resource materials easily accessible by families, internal and external clinicians within the tertiary and
primary settings enabling education about and compliance to implement the new model of care
.
Results:
Comparative analysis was conducted 12months post implementation of the interventions and Planned Model of Care. The
results showed that despite a 23% increase in presentations in comparison to the baseline period the following was
achieved:
•
7% Reduction in the number of patients admitted for DRG – L63B (Typical UTI)
•
25% Reduction in Average LOS for DRG – L63B
•
80% of inpatients were now discharged within 2 days, an improvement of 24%
•
25% Reduction in Bed days used for DRG L63B
•
68 Actual Bed days and 148 Extrapolated Bed days saved over 12 months
•
An increase of 973 hits on the website for viewing of the UTI Fact Sheet in the 6 month 2010 period
Conclusions:
a) Application of Redesign Methodology can simultaneously improve clinical practice as well as patient flow.
b) Project Objectives were achieved by converting evidence into practice and ensuring that children are no longer
admitted to a tertiary level facility when appropriate care and support is not only indicated but available within their local
community setting.
c) Knowledge gained includes the importance of engaging clinicians in developing and implementing any clinical practice
changes, that electronically accessible information and resources for families and clinicians should be available to support
the clinical practice changes, that the methodology and knowledge gained from this project is easily replicable and could
be applied to other patient cohorts.
0344
The analysis of drug disposal on patient medication behavior in a medical center
Hsuan-Lin Wen, Ping-Yu Lee, Hsin-Ling Pang, Yi-ping Hsiang
Chang Gung Memorial Hospital - Kaohsiung Medical Center, Kaohsiung, Taiwan
Objective:
A medical center recovered drug disposal from 1999, average 20 kilogram disposal amount per month. To avoid to
acuumulate not-used drug at home and prevent secondary enviromment pullotion, we enhance to educate the general
public to return the not-used drug(out of expired,deteriorated,no indication and so on) to hospital from 2010 May. We
destroy them by burning or melting integrately.
Methods:
This study collected the drug disposal in a medical center from 2010May to December; we set up a disposal center
located on drug information counter. Standard form be designed, classified item of drug, prescribed department, the
reason of recovery. To poster in public crowd to remind the information, provided the education sheet and exhibited a
serious of lecture courses to improve the recovery policy of drug disposal.
Results:
Total seven months study period, 573 patients took drug disposal to recovery center, not-used medicine were 1806, gross
weight 391 kg, average about 49 Kg disposal amount per month. The results revealed that most prescribed department of
the drug disposal were neurology (17.5%), cardiology(11.5%) and nephrology (8.9%) respectively; The mechanism of
drug dispodsal action of were gastrointestinal(15.2%), antihypertensive(12.5%), anti-inflamative agent(8.7%), central
nerve system (8.5%) and hypoglycemia agent(5.8%) respectively；The reason of recovery were did not want to take it
(26.2%), out of expired (14.4%) and condition improving (13.5%). We analysed the expenses of drug disposal on
November were 187,696.3 NT, and the first 3 were antihypertensive 60,068.5 NT (32.0%), anti-inflammative 35,005.4 NT
(18.7%) and hypoglycemia agent 29,445.9 NT (15.7%) respectively.
We surveyed the questionnaire from the general public, discoveried that about 60 % patients who’s family had chronic
disease and usually kept medicine at home.
Conclusions:
In this research, our conclusions were that the reason of drug disposal most caused by chronic and symptom relief and
the waste of medicine were very significantly. If patient only took the prescription from doctor, but they did not take them
to treat disease, we must confer the true reason. Loss of confidence to medical treatment, poor education to compliance;
or overlaping medicine, overlaping consulting, cognition insufficiency…. Augmenting the correct patient medication
behavior by use the medicine record or strengthen patient education was very important issue for patient drug safety.
0346
The implementation of CHARM, an oncology patient information management system at a specialist cancer
hospital.
Michelle Hong, Suzanne Graham, Dennis Carney, Sue Kirsa
Peter Mac Cancer Centre, Melbourne, Victoria, Australia
Objective:
To improve documentation, accountability, communication and safety of chemotherapy prescribing through the
implementation of an oncology patient information management system.
Methods:
The oncology information management system, CHARM, was implemented by a project team consisting of a pharmacist,
nurse and project leader over a 12 month period. A database of drugs, chemotherapy protocols and other resources was
created to accommodate the hospital setting. Chemotherapy pathways were then developed according to guidelines and
hospital policy, and approved by individual tumour stream clinicians, with 551 pathways including 73 trials currently active.
Training was provided to nurses, pharmacists and other clerical staff, with individual training provided to prescribers.
Ongoing internal support is provided by a system administrator and a pharmacist. External support is provided by
charmhealth via a helpdesk, and with regular site visits. A committee represented by doctors, nurses and pharmacist
meet monthly to review issues relating to upgrade and maintenance of the system.
Results:
•
Eliminates hand-written chemotherapy orders resulting in more legible, standard and ultimately safer prescribing
amongst clinicians. All relevant information (patient details, allergies, alerts, premedications, fluids and recommended
discharge medications) is available on the system to assist prescribing. The process of dose adjustments or changes
to treatment for individual needs, once decided by the clinician, is made visible to all members of the treating team on
CHARM.
•
Provides an effective booking and scheduling system for the Chemotherapy Day Unit. Resources
(bed/chair/treatment time) are allocated to chemotherapy pathways which are applied when scheduling a patient for
treatment.
•
Provides an efficient system for the Cytotoxic Manufacturing Suite in Pharmacy who manufacture all chemotherapy
on site. The system generates manufacturing worksheets, provides a log of products which can be recycled to reduce
wastage, and tracks patients’ arrival to ensure orders are processed in a timely manner. Products can be
manufactured in advance, as soon as a pathway is assigned to a patient, effectively reducing waiting times.
•
The internal reporting tools can capture an extensive amount of data including patient arrival times, pharmacy orders,
commencement of treatment and patient discharge. This data has markedly improved the reporting of Key
Performance Indicators.
•
Currently not interfaced with the hospital’s electronic medical records, pharmacy dispensing program or pathology
service.
Conclusion:
The implementation of CHARM has eliminated transcription errors but not prescribing errors. There is a potential risk of
prescribers becoming less knowledgeable with protocols as prescribing is more automatic. However, chemotherapy
orders are more legible and standardised with respect to chemotherapy drugs, doses and supportive care drugs used.
The lack of integration with other systems used in the hospital has not been fully resolved, however, CHARM has assisted
in better workflow and provided a more efficient booking system for the Chemotherapy Day Unit. More positively, the
system has proved to be an effective form of communication amongst health professionals.
0347
Dynamic internet mediated teamwork case management of high frequent emergency department users
Charng-Yen Chiang, Kuan-Han Wu, Chao-Jui Li, Wen-Huei Lee
Chang Gung Memorial Hospital, Kaohsiung, Taiwan
Objective:
To assess whether dynamic internet mediated teamwork case management of high frequent emergency department (ED)
users reduces subsequent attendances made by these patients.
Methods:
Since June 2010, patients who attended the ED 3 times within 72 hours or more each month were identified. These cases
were assessed by expert panels and initial care plans was developed and listed in interior website. Thereafter, each
emergency physician could adjust the care plans dynamically via interior website according to patient’s condition and
communicate result. Care plans were revised gradually by teamwork to meet patient’s clinical situation. Patient
attendances over the subsequent 6 months were compared.
Results:
16 patients attended the ED 3 times within 72 hours or more in May and June 2010. These 16 patients account for totally
904 visits in the 6 months periods before intervention. The average number of ED attendances in this patient group was
9.42. In the subsequent 6 months following case management of these patients, median attendances in the same 16
patients dropped to 4.07 (p<0.001). The total number of attendances in this patient group dropped from 904 to 391, a
reduction of 56.74%.
Conclusions:
The findings of this study suggest that dynamic internet mediated teamwork case management may help to reduce
subsequent attendances in patients who frequently attend ED.
References:
1. J Skinner, L Carter, C Haxton. Case management of patients who frequently present to a Scottish emergency
department. Emerg Med J 2009;26:103–105.
2. Jonathan Woodhouse, MA, Mary Peterson, PhD, Clark Campbell, PhD, ABPP/CL, and Kathleen Gathercoal, PhD,
Newberg, OR. The efficacy of a brief behavioral health, intervention for Managing High ultilization of ED services by
chronic pain patients. J Emerg Nurs 2010;36:399-403
3. Starfield B. Primary Care: Concept, Evolution, and Policy. New York: Oxford University Press; 1992.
4. Lee KH, Davenport LD. Can case management interventions reduce the number of emergency department visits by
frequent users? Health Care Manager 2006;25:155–9.
5. Spillane LL, Lumkb EW, Cobaugh DJ, et al. Frequent users of the emergency department: can we intervene? Acad
Emerg Med 1997;4:574–80.
6. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED
frequent users. Am J Emerg Med 2000;18:603–8.
7. Pope D, Fernandes C. Frequent users of the emergency department: a programme to improve care and reduce visits.
Can Med Assoc J 2000;162:1017–20. Bernstein SL. Frequent emergency department visitors: the end of
inappropriateness. Ann Emerg Med 2006;48:18–20.
0348
Comparison of effects of disclosure training of adverse events between medical students and resident
physicians
Kaori Takada, Mio Sakuma, Susumu Seki, Takeshi Morimoto
Center for Medical Education, Kyoto University Graduate School of Medicine, Kyoto, Japan
Objective:
We assessed the effectiveness of disclosure training of adverse events for medical students but such effectiveness for
front-line physicians is still unknown.
Methods:
We developed disclosure training of adverse events with simulated patients. 2nd year medical students and 1st year
resident physicians were presented the hypothetical scenarios of adverse events with errors, and asked to be a
healthcare professional in charge. They have to explain the incidents to the simulated patients. The disclosure was
conducted twice for different scenario and simulated patients. After the explanation, students and residents as well as
simulated patients fulfilled the questionnaires asking the following domains: fullness of explanation; satisfaction of family;
apology; sincerity; feeling bewildered and disclosure about error. Simulated patients were also asked about their intention
to continue the care and to sue the doctor. These domains were rated by 5-scale. 10-scale global quality of explanation
was graded by both students/residents and simulated patients. We conducted descriptive statistics followed by one
sample t-test to compare the change in domains between two disclosures. We compared the changes in domains
between students and residents.
Results:
46 medical students and 22 resident physicians enrolled in this study. The mean global quality of explanation was 4.8
and 4.7 in students and residents, respectively. The baseline scores of satisfaction (2.7 vs. 2.1), apology (3.8 vs. 3.1),
and disclosure about error (4.3 vs. 3.0) were significantly higher in students than residents by self-rating. From the
perspective of simulated patients, all domains were significantly higher in students than residents. The intension to
continue the care was also significantly higher (3.2 vs. 2.4) in students than residents.
After the 1st disclosure session, the self-rating scores of many domains in students significantly changed (4 improved; 2
worsened), but only one domain (satisfaction) of residents improved (Table 1). On the other hand, the scores of
simulated patients of all domains in residents significantly improved meanwhile those in student did not (Table 1).
Conclusion:
The effects of disclosure training were significantly different between medical students and resident physicians in terms of
first response as well as change after training. The changes from patient perspective were significantly larger in residents,
and such difference might be associated with the actual experience in patient care. Our findings should be attested by
bigger and long-term studies.
Table 1. Change in Quality of Disclosure among Students and Residents
0349
Application of Radio Frequency Identification (RFID) for Surgery Scheduling Management
1
2
1
Hsueh-Ling Ku , Jun-Der Leu , Pa-Chung Wang
1
2
Cathay General Hospital, Taipei, Taiwan, National Central University, Taoyuan County, Taiwan
Objective: To discuss the effectiveness of managing and controlling the earliest start time and turnaround time for
surgeries in operating rooms.
Methods: This study used a prospective approach and investigated surgery scheduling management using the
automated phone instant messaging function of the RFID system to send messages to the operator. This study assessed
the difference in operational efficiency before and after the function was integrated.
Results: Use of the automated phone instant messaging function reduced the delay rates of earliest start times for
surgery from 39.2 % to 31.1 %. The average duration of delay decreased from 17.9 to 15.69 minutes. The duration of
turnover time decreased from 25.20 24.89 minutes. The cost of phone calls per surgery decreased from 6NTD to 1.5NTD.
The rate of satisfaction with the function was 96.1 % among doctors and 96.6 % among nurses.
Conclusion: Using the value-added functions of the RFID system in the operating room offers many advantages:
reduction of cost, increased efficiency, instantaneousness, convenience, easy access and improved patient safety. These
functions create a platform for clear communication, increase the operational efficiency of surgery scheduling, reduce the
cost of phone calls in the operating room, and raise the level of job satisfaction among medical personnel.
0351
HFMEA model : prevent an inappropriate initial dose prescribing
Agnes Chan, Hui-Yu Wang, Yeh, Chun Lan
Chi Mei Medical Center, Tainan, Taiwan
Objectives: Apply healthcare failure mode and effects analysis on the improvement of an inappropriate initial dose of
aminoglycosides prescribed in the intensive care unit of a medical center in Taiwan.
Methods: A multidisciplinary team includes clinical pharmacist, physicians and nurses. The clinical pharmacist identified
the potential failure modes in the process of prescribing inappropriate dose of aminoglycosides in the ICU and by creating
a flow char. The team members brainstormed all possible steps that could produce the prescription of inappropriate dose
of aminoglycosides conduct a hazard analysis and calculate a hazard score. We also implemented the computerized online pharmacokinetic calculation formula( first-order infusion input model) into the physician order entry system at all the
intensive care unit except pediatric ICU in July 2002 in order to help physicians to predict patient’s dosage.
Results: The original process was identified eleven possible effects that may result in the inappropriate initial dose of
aminoglycosides in the ICU. HFMEA showed that four possible modes had high hazard score (Remain previous dosage
from the ward =12.3, lack of knowledge of using pharmacokinetic formula=12.3, neglect drug-kidney function
relationship=12.0, not check kidney function periodically=12.3) in the original process. After the implementation of the online calculator, the hazard score for the four modes were decreased (Remain previous dosage from the ward =2.25, lack
of knowledge of using pharmacokinetic formula=0.25, neglect drug-kidney function relationship=0.25, not check kidney
function periodically=6.25) The results showed that the percentage of the number of patients received the inappropriate
initial dose was decreased from average 32.6%± 10.5 before the implementation of the calculation system to 14.14 % ±
4.9 after the implementation of the system.
Conclusion: HFMEA was used to identify the most severe modes which may cause inappropriate dose of
aminoglycosides antibiotics prescribed by physicians in the ICU that led to medication errors in our hospital. The
implementation of the on-line dose calculator helps physicians to predict the initial dose of the aminoglycosides more
accurately which resulted in more accurate blood concentration and fewer medication errors.
0354
IMPROVING DRUG SAFETY OF CLINICAL TRIAL SUBJECTS BY UTILIZING INFORMATION TECHNOLOGY
Yu-Chan Kang, Ping-Yu Lee, Shu-Chen Liu, Ming-Hong Chen
Department of pharmacy, Chang Gung Memorial Hospital-Kaohsiung Medical Center & Chang Gung University College of
Medicine, Kaohsiung, Taiwan
Objective: To establish, based on the Hospital Information System, a management mechanism for clinical trial drug
safety related logistics and prescription orders, with the purpose of providing subjects with safe and effective
pharmaceutical services.
Methods: Computerization of investigational drug encoding advanced from 2007, and is archived under Storage
Operations of the Hospital Information System. The system is hence utilized to conduct the following pharmaceutical
managements:
1. Inventory management:
Information, such as the inventory stock, of investigational drugs stored over three months without administration, and
drug administration under 1/10 of total stock each month, can be accessed and traced. Trials status, whether it’s pending,
late, or on time, can thus be easily monitored.
2. Quality management:
The expiration date and batch number of stored or dispensed investigational drugs can be acquired.
3. Administration management:
The way of investigational drugs administration can be inquired. The correctness of the investigator’s prescriptions can
thus be verified.
4. Prescription management:
Trials conducted after 2008 (new trials) must be listed in the “Physician Order Protection System”. Earlier existing trials
are not included. This system can halt drug dispense for trials not completing required procedures during trial period. It
is used as a reminding warning, for investigators and pharmacists, the appropriateness of drug prescription and
dispensing, respectively.
5. Subject administration:
The name and usage directions for the investigational drugs can be provided in the outpatient subjects’ medical
packets and listed in their subject diary cards, to enhance the safety of drug administration. It can also be listed in the
prescription orders of inpatient subjects to increase the correctness of drug dispensing for pharmacists and medical
staffs.
Results: The portion of computerized encoded investigational drugs increased from 15% in 2007 to 100% in 2009. There
were 150 clinical trials (86 new trials, 64 existing trials) conducted in our hospital between 2009 and 2010; the average
number of trials managed by the pharmacist was 82.9 trials per month. 19 cases (9.3% new trials (8/86), 17.2% existing
trials (11/64)) were halted drug prescription due to incompletion of required procedures within trial period. Amongst these
cases, 10 cases (4.7% new trials (4/86), 9.4% existing trials (6/64)) were due to incompletion of annual report submission;
9 cases (4.7% new trials (4/86), 7.8% existing trials (5/64)) were due to incompletion of other administrative procedures.
Of all halted cases, the portion of which medical order could still be prescribed under an incomplete annual report
submission procedure is 0% for new trials (0/4); 100% for existing trials (6/6). Therefore, the system could 100% intercept
trials not completing the required annual report process, and hence reducing concerns that might arise regarding the
inappropriateness in drug prescription.
Conclusion: As investigational drugs are mostly not marketed, their prescription and dispense should be managed
specifically. Our establishment, within the Hospital Information System, of the management mechanism for clinical trial
drug safety related logistics and prescription orders, can improve drug safety of clinical trial subjects.
0357
PATIENT SAFERY CULTURE SURVEY IN COMMUNITY HOSPITAL
KuanHui Lee, Peter Woo, Hsiu-Man Chiang, Hon-Kwong Ma
Cardinal Tien Hospital Yung Ho Branch, Taipei, Yung Ho, Taiwan
Objective:
Using the Safety Attitudes Questionnaire (SAQ) to evaluate patient safety attitudes of employees in a community hospital.
Methods:
In collaboration with Taiwan Joint Commission on Hospital Accreditation, the authorized translated Chinese version of
Safety Attitudes Questionnaire (SAQ), developed by Dr. Bryan Sexton of University of Texas, was used to evaluate the
patient safety attitude perspectives of healthcare providers in a total of 23 units in our hospital. The questionnaire consists
of 40 items, including 5 dimensions: teamwork climate, safety climate, job satisfaction, perception of management, and
working conditions (stress recognition). The questionnaire survey utilized the Likert 5-point Scale, ranging from ‘disagree
strongly’ to ‘agree strongly’ with a corresponding score of 1-5, while the ‘not applicable’ scale was considered as a system
missing value. A high questionnaire score correlated to a high degree of agreement. There were 382 participants, with a
response rate of 91.88%. Using cross-sectional survey study, apart from individual background information and items
descriptive analysis, t-test and ANOVA were also used to compare the scores in patient safety dimensions among
medical staffs in different units or with different background information.
Results:
Regarding the positive percentage among various dimensions, the perception in management had the highest percentage
(51.88%), followed by teamwork climate (50.89%), with the lowest percentage in working conditions (33.03%). However,
unit safety climate dimension had the highest average score (M=26.56), but the score was lower in working conditions
dimension (M=14.12). Results implied a higher positive perception of the organization safety assurance by the staffs,
whereas a relative negative perception of working conditions and resource supply (e.g. manpower and equipment) was
noted especially among pharmacists, radiology technicians, and nurses with lower corresponding scores.
Conclusions:
In conclusion, the patient safety attitudes and perceptions of our hospital attained medium to high level when compared to
similar organizations. However, there is a world-wide trend aiming at establishing patient safety culture in organizations.
Results from more and more research revealed that there is an obvious correlation between the safety attitudes of
medical staffs and unit safety climate, adverse events, and patient safety, also affecting the quality of care. Therefore,
through the results of annual patient safety culture survey, by establishing the aims of our annual patient safety plan in our
hospital, we can provide a better healthcare quality.
0366
Continuous Quality Improvement on the Discharge Process of Orthopaedic Patients
Teresa FY Li, KY Cheung, YY Choi, KC Mak
Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hospital Authority, Hong Kong SAR, China
Objective:
To improve the patient experience in the discharge process, and enhance quality and continuity of care of patients
discharged from acute to convalescent hospitals and home
Method:
The continuous quality improvement and lean management approach were adopted.
(A) Gap Analysis to identify improvement opportunities in patient discharge process
Relevant workflows on the patient discharge and transfer processes from acute to convalescent hospitals were analyzed
by a multi-disciplinary team. Findings of Gap Analysis were:
(i)
Patient educational pamphlets which were supposed to be distributed to patients for subsequent self care at
home were found unavailable to patients upon discharge from hospital;
(ii)
The process of transfer to convalescent hospital was found to be an unpleasant experience to both the patients
and staff. Over 30% of the patient transfers were later than the scheduled arrival time at the convalescent hospital leading
to delays in doctors’ admission screening there; and
(iii)
Nursing staff had to spend a lot of time and effort to coordinate with convalescent hospitals on bed availability and
get everything ready in order to keep to the patients’ transfer schedules.
(B) Formulation and Implementation of improvement actions
(i)
A Patient Education Pamphlet Folder (pamphlet folder) was designed and made available in the wards as easy
reference and reminder for nursing or ward staff to distribute education pamphlets to appropriate patients;
(ii)
The patient transfer process was streamlined resulting in fewer number of telephone calls between the acute
wards and convalescent hospitals required and reduced effort in coordination of convalescent beds for admission of
discharged patients from the acute hospital; and
(iv)
The patient discharge process was further expedited, with support by concerned doctors, by introduction of
improvement actions such as having a notice board to show the patient’s discharge status, namely, `not for
discharge’ denoted by a red dot; `plan for discharge’ by a yellow dot and `for discharge’ by a green dot. In this
way, the interns and other ward staff could prepare the discharge documents and complete any other necessary
arrangements to facilitate the transfer in time and early booking of transportation.
Results:
•
The compliance rate of distribution of patient educational pamphlets to patients prior to discharge has improved
from 18% to 100%
•
Staff members were satisfied with the use of the new pamphlet folder for reasons of `able to save time’,
`usefulness’ and `being user friendly’. The average satisfaction score was 4.35 over a scale of 1 (least satisfied) to
5 (most satisfied)
•
The time required for making telephone calls for convalescent bed coordination was reduce by 50%, from 240
minutes to 120 minutes per week
•
The discharge documents for patient transfer to convalescent hospital were ready in time to ensure that all patients
were transferred on the same day without delay
Conclusion:
The various patient discharge and transfer tasks and processes can be smoothly coordinated, streamlined and effectively
implemented through multi-disciplinary participation and continuous quality improvement. A proper and well executed
discharge and transfer process can enhance quality and continuity of care of patients across hospitals, and improve
patient and staff experience.
0372
Nurse-Led Prostatic Screening Clinic for Early Identification and Management of Patients with Lower Urinary
Tract Symptoms
Lui Ka Lok Gilbert, Ho Wai Fan, Tai Chi Kin Dominic, Fan Chi Wai
PYNEH, Hong Kong
Objective:
To evaluate the effectiveness of nurse-led prostate screening clinic in early identification and management of patients with
lower urinary tract symptoms (LUTS).
Methods:
A retrospective review of patient notes on new patients who attended the nurse-led clinic prostate screening clinic during
October 2008 to December 2010. Patient history, and investigation results which included the International prostate
symptom score (IPSS), Urine for culture+ Cytology, CBC, LFT, RFT & PSA, Flow Rate + Post void residue urine and KUB
were analysed. The waiting time for first consultation by an Urologist to an Urologist Nurse Specialist was compared.
Results:
497 new patients attended the nurse-led prostate screening clinic. In which, 177 patients (36%) were timely identified and
requiring early medical attention due to the following conditions:
14 patients (3%): urinary tract infection
84 patients (17%): urinary stones
53 patients (11%): elevated PSA
16 patients (3%): suspicion of urothelial carcinoma
10 patients (2%): chronic retention needs immediate catheterization
In compared with an observational study with retrospective review of 3548 LUTS patients aged over 50 done by Nilay et
al (2008) in UK, 640 patients (18%) had elevated age specific PSA, of which 153 were subsequently diagnosed with
prostate cancer (incidence=4.3%). 68 patients (1.9%) had abnormal urine cytology or ultrasound scans suspicious of
bladder cancer which resulted in 16 new bladder cancers (incidence=0.5%).
The mean waiting time for first consultation to provisional diagnosis was reduced from 110 weeks to 16 weeks (↓85.5%).
In compared with an observational study of one stop prostate clinic done by Chau (1999) in Kowloon Central Cluster, HK,
st
the mean waiting time from 1 consultation to provisional diagnosis was reduced from 91.33 days to 38.25 days. (↓58%)
Conclusions:
With introduction of prostatic screening clinic, the waiting time of patients with LUTS was markedly shortened. It also
enabled early identification of patients who required early medical attention. The prostatic screening clinic significantly
reduced the delay for patients to be seen at the hospital and facilitated rapid assessment and investigation, much of which
was carried out by a urology nurse specialist during the first visit. All these results would be available and screening by
urologist before patients had second visit to the prostatic screening clinic. This practice allowing a provisional diagnosis to
be made; treatment plans to be discussed with patients by urology nurse and drug treatment to be offered to the suitable
cases.
The underlying implication for this project was that by moving away from the traditional practice and providing patients
with this additional access, education, and support, patients would be more adherent to drug monitoring, prostatic
screening and necessary dietary modification. It was also believed that the nurse would take on the responsibility of
follow-up care, easing the burden on the urologist. Some insightful results from this retrospective review can help the
design and execution of new healthcare practice and act as a demonstration of impact of the new practice on patient
treatment outcomes.
0373
Independent Predictors of Peri-operative Outcomes in Orthopaedic Surgery: Influence of Timing of Preoperative
Myocardial Infarction and Stroke
1
2
1
1
Alex Bottle , Kennedy Lees , Paul Aylin , Robert Sanders
1
2
Imperial College London, London, UK, Glasgow University, Glasgow, UK
Objective: To determine the independent preoperative predictors of perioperative outcome in orthopaedic surgery, with a
focus on the influence of timing of prior acute myocardial infarction (MI) and stroke.
Methods: The Hospital Episode Statistics database in England was analyzed for elective admissions for total hip (THR)
and total knee (TKR) replacements between 2005 and 2009. Independent preoperative predictors of perioperative
outcome were identified via comorbidity fields. As stroke and MI each showed a strong relation with mortality, we aimed to
address the effect of timing of these preoperative events, as our administrative data cannot distinguish between
comorbidities and complications. We therefore searched back four years in time for each patient for admissions for
preoperative strokes (separating the TIAs) and myocardial infarctions. In patients with prior stroke defined in this way, we
fitted new models that included the time interval between this prior event and the index procedure; we repeated the
process for prior MI. The time interval was handled in two ways: i) assuming a linear relation with the outcome, and ii) by
comparing intervals of <6 months (as done in an old study) with intervals of between 6 months and 4 years. Perioperative
mortality was defined as in-hospital death within 30 days of the index procedure. Long length of stay and unplanned
readmission rates were used as surrogates for perioperative morbidity.
Results: Nearly 600,000 hip and knee replacements were analysed with mortality rate 0.2% and unplanned 28-day
readmission rate 6.0%, and the 75% percentile for length of stay was 8 days. Independent predictors of death using the
comorbidity fields included stroke (OR=8), MI (OR=22), various heart diseases, chronic respiratory disease, diabetes and
liver disease. When stroke and MI were determined instead from admissions in the previous four years, a higher risk of
death was also found for stroke (OR=1.86, p=0.017) but not MI (OR=1.08, p=0.73); however, prior admission for stroke or
MI was associated with a higher risk of readmission and long stay (see Table). The risk for stroke was higher than the risk
for TIA.
Table summarising relation between stroke or MI admission in 4 years prior to THR or TKR and the three outcomes
Prior
admission
Death
OR
Readm28
P
OR
Long LOS
P
1
OR
P
None
1
1
Prior TIA
1.23 (0.56 to 2.69)
0.608
1.31 (1.08 to 1.58)
0.006
1.66 (1.47 to 1.86)
<0.001
Prior stroke
1.86 (1.12 to 3.10)
0.017
1.42 (1.24 to 1.63)
<0.001
2.18 (2.00 to 2.37)
<0.001
None
1
Prior MI
1.08 (0.69 to 1.71)
1
0.733
1.39 (1.25 to 1.54)
1
<0.001
1.51 (1.41 to 1.61)
<0.001
In the analysis considering patients only with prior stroke or TIA in the previous four years, the relation between the timing
and the outcome was usually unclear, as it was when considering patients only with prior MI in the previous four years.
The only exception was for prior stroke and long LOS, which suggests that the highest risk is for patients with a stroke in
the last six months (OR=1.53 compared with less recent stroke, p=0.011).
Conclusions: Admission in the previous four years for either stroke or MI was associated with higher risk of adverse
perioperative outcomes. Consideration should be given to delaying orthopaedic surgery to after six months following a
stroke.
0374
Business Intelligence and Cloud Computation Application for Healthcare Quality – The Use of National
Healthcare Insurance Reimbursement Data
Chia-Hui Cheng, Sheng-Hui Hung, Wan-Ting Wu, Pa-Chun Wang
Cathay General Hospital, Taipei, Taiwan
Objective:
Due to escalating costs and public concern about quality and patient safety, health care providers are in an urgent need to
obtain organization performance data in time to take immediate correction actions for the pursuance of better clinical
outcomes and to maintain excellence in business performance with the use of business intelligence, cloud computation
technology, and healthcare claim data in hospital quality management.
Methods:
Business intelligence, a technique to gather information from data warehouse and to transform them into meaningful
information, is embraced in various industries to improve reporting and decision-making processes. Since the
implementation of National Healthcare Insurance (NHI) in 1995 in Taiwan, 22.9 million people (>97% of the total
population) are covered, which constitutes a relatively comprehensive healthcare reimbursement claim data for the entire
population. In this study, an in-house, web-based quality indicator platform was established with the application of
business intelligence and cloud computation technology; claim data are input into this platform to generate quality data
monthly. The web-based platform is developed by ASP.net 2.0 Development Kit on the Net Framwork 2.0 platform.
Results:
Around 400 indicators are generated. Indicators are categorized into utilization of care, financial operation, disease
management, guidelines compliance in medication, as well as other clinical outcomes. The hospital executives and
managers can access quality indicators retrospectively or concurrently through the intranet. The system provides various
types of graphs and can drill down data into several metrics to identify the factors that affect quality performance. The
real-time quality indicator platform offers the hospital executives more effective measures of performance, quicker
responsiveness to change, regular reports to achieve continuous improvement via indicator monitoring.
Conclusions:
In the ever-changing and cost-containing healthcare environment, only the healthcare organizations, which can manage
their real-time performance, will excel among competitors. In the study, it is proven that healthcare business intelligence
and cloud-based indicator platform can provide analytic information to help healthcare organizations on effective
performance-evaluation, accurate strategic decision-making, and alignment to organizational goal.
0375
Decrease of waiting time and improvement of outpatient satisfaction
CHIA-HAO HU, You-Meei Lin, Ying-Chih Huang, Wuan-Jin Leu, Chia-Hao Hu
Taipei Medical University -Shuang Ho Hospital Pharmacy Department, Taipei, Taiwan
Objective
This study aimed to improve the waiting time and patient satisfaction at an ambulatory pharmacy after an intervention of
management techniques to improve quality of health care.
Methods
We initiated the management techniques in an ambulatory pharmacy by purchasing the second high-speed printer for
printing the Refill and discharged medications, differentiating the delivery desk of discharged and refill, reallocating certain
patients to the pharmacy help desk to delivering and consulting their medication simultaneously, and adjusting manpower
during the rush-hours of dispensing and checking. Waiting time was assess from the time the medication been billed to
the time patient receives the medications. The Peak waiting time was further specified within 10:00 to 12:00 in the
morning of the waiting time. Less than the threshold of “10 minutes” waiting time indicates a better patient experience. A
follow-up survey conducted before and after the intervention to evaluate patient experience during the ambulatory care.
Results
Ambulatory pharmacy waiting times have been shortened significantly after the implementation of our management
techniques on February 2010. The average daily waiting time and peak waiting time were both bellowed the threshold,
which revealed 7.03 minutes in before to 6.24 minutes in after the intervention, and 8.58 minutes in before to 7.67 minutes
in after the intervention, respectively. Patients’ perception on waiting time at ambulatory pharmacy was also altered, and
the survey showed that the patient satisfaction rate elevated from 60.1% in pre-intervention to 62.6% in post-intervention.
Conclusions
Waiting time is a significant component of patient satisfaction which correlated to the health care quality. However, patient
safety on medication is the fundamental to high-quality healthcare, which can not pose a risk while shortening waiting time.
Our management techniques improved the pharmacy practice to maintain patient safety, and concurrently, elevated
patient satisfaction.
0378
Obstetric Incident reporting in Ministry of Health (MOH) Hospitals, Malaysia 2008-2009
1
2
2
Ravindran Jegasothy , Kalsom Maskon , Paa Nazir
1
2
Hospital Kuala Lumpur, Kuala Lumpur, Malaysia, Ministry of Health, Putrajaya, Malaysia
Objective:
The purpose of this paper is to document the evolution of the Obstetric & Gynaecologic based indicators in the Incident
Reporting System of the publicly-funded Ministry of Health, Malaysia hospitals and to analyse the data for the years 20082009.
Methods:
The Malaysian Incident Reporting System was developed as a confidential system. The reporting system form provided
for a structured format as well as a narrative description of events for analysis. Forms were analysed at the local level and
aggregated numerical data submitted to the Quality Secretariat at the Ministry of Health, Malaysia. Remedial actions were
taken at the local level.
Results:
The first indicator was poor Apgar score (defined as a score of 7 or less) which could be a reflection of intrapartum care.
Another indicator was injury to the neonate at delivery. The occurrence of such an event could indicate an issue with
obstetric judgment regarding the mode of delivery as well as the competency and experience of the accoucheur. The third
was death of a fetus weighing more than 800grams. However this indicator proved insufficiently discriminative for analysis
regarding patient safety events and was anyway already the subject of the national perinatal mortality investigation.Other
obstetric indicators developed were unplanned admission of the mother to high dependency or intensive care areas postdelivery and unplanned post-delivery procedure on the mother. As these indicators capture unexpected events,
investigations would reveal possible quality issues in assessment pre-delivery and lack of adequate specialist involvement.
Another proposed indicator for 2011 was unsuccessful ventouse/forceps delivery which suggests a wrong choice of
instrument and inadequate pre-delivery assessment.
There were 1,947 infants with a poor Apgar score amongst 269,710 deliveries in 2008 with an incidence of 7.21 per 1000
deliveries. In 2009, there were 2,461 infants with poor Apgar score out of 327,041 deliveries, giving an incidence of 7.53
per 1000 deliveries, a slight increase in rates. In 2008, there were 235 injured neonates with an incidence of 0.9 per 1000
deliveries. In 2009, there were 239 injured neonates, with an incidence of 0.72 per 1000 deliveries. In 2008, there were
1674 fetal deaths with a birth weight of > 800grams with an incidence of 6.20 per 1000 deliveries while in 2009, there
were 2,132 fetal deaths with an incidence of 6.5 per 1000 deliveries.
There were inter-state differences which could not be correlated to the number of specialists or to the socio-economic
status of the states. The reasons for poor Apgar score could not be correlated nationally at the moment as the incident
reporting system is confined to Government-run hospitals of the Ministry of Health and is not truly “national”
In a national referral hospital, the main reasons for poor Apgar score were obstetric reasons. Another group of patients
could be attributed to delayed recognition or delayed response to cardiotocographic abnormalities in labour. Action was
taken to address this issue by organising regular training sessions on CTG interpretation and the placement of a specialist
in the labour ward at all times to provide immediate supervision and consultation. Similarly for the prevention of birth
injuries which ocurred frequently during caesarean sections, a hand-off format was implemented so that the medical
officer who decided on a caesarean section could evaluate the surgical risks and inform the medical officer performing the
caesarean section
Conclusion:
The Malaysian Incident Reporting System for obstetric cases has evolved from reviewing the initial incidents to include
more relevant ones whilst maintaining the useful ones.Actions can be taken at the local level which could reduce the root
causes for some of these incidents. These actions can be translated to national policy which would improve the quality of
care. Local champions and a facilitative national environment are required to improve quality of care.
0380
Development and validation of a clinical prediction rule to identify the patients with higher risks of ADEs during
hospitalization: the JADE Study
1
1
2
1
Mio Sakuma , Susumu Seki , David W Bates , Takeshi Morimoto
1
2
Kyoto University Graduate School of Medicine, Kyoto City, Japan, Brigham and Women's hospital, Boston, MA, USA
Objective: To develop and validate the model that identifies patients with higher risks of adverse drug events (ADEs)
during hospitalization.
Methods: The Japan Adverse Drug Events (JADE) study is a prospective cohort study at three teaching hospitals in
Japan to assess the frequencies of ADEs and factors associated with the occurrences of ADEs. The study includes 3459
participants, and they were randomly assigned to the derivation set and the validation set at a ratio of 1 to 1. In the
derivation set, the univariate relationships between the occurrences of ADEs and patients’ clinical factors which were
evaluated on admission were assessed using Chi square or Fisher’s exact test when those variables were categorical and
t test or Wilcoxon test when they were continuous. The variables univariately associated with the occurrence of ADEs
(P<=0.2) were entered into a stepwise logistic regression analysis and variables with P values <=0.05 were retained in
that model. The prognostic ability of the model was estimated by measuring the area under the receiver operating
characteristic (ROC) curve (AUC) in the validation set.
Results: In the derivation set (n=1729), at least one ADE occurred to 376 patients (21.7%). 46 factors were selected by
univariate analyses, and 12 factors were identified as independent risk factors by stepwise logistic regression: Age>= 65
years old, a doctor in charge (resident), scheduled operation, dyspnea, consciousness alert, burden of illness such as
dementia, rheumatologic, hemiplegia and cancer, scheduled medications such as laxatives and analgesics, medications
prescribed on admission such as antipsychotics. AUC of this model in the derivation set was 0.69; 95%CI 0.65-0.72. The
validation set contained 1730 patients, of whom 350 patients had at least one ADE during their hospitalization (20.2%).
Applying the model established in the derivation set for the patients in the validation set, AUC in the validation set was
0.63; 95%CI 0.60-0.66. When the probability threshold of having ADEs is 50%, 80% of 1390 patients in the validation set
were correctly classified. Performance of the model is shown in Table below.
Conclusions: This model would help clinicians identify the patients with higher risks of ADEs during their hospitalization
and would also assist clinicians to detect ADEs earlier.
Table. Performance of the model
Probability
<0.2
0.2=<, <0.3
0.3=<
ADEs occurred
135 (13.5)
107 (25)
134 (44.1)
No ADEs occurred
863 (86.5)
320 (75)
170 (55.9)
ADEs occurred
153 (15.3)
133 (24.9)
64 (32.7)
No ADEs occurred
847 (84.7)
401 (75.1)
132 (67.3)
Derivation set (N=1279)
Validation set (N=1730)
0383
A Delphi study for the development of quality indicator system of psychiatric hospitals in Korea
Jin-Seok Lee, Chae-Eun Lee, Sun-Young Lee
Seoul National University, Seoul, Republic of Korea
In Korea, hospital evaluation and public disclosure programs were started in the early 2000s and these brought
improvement of hospital quality. But, psychiatric hospitals were ruled out these programs that was important cause of
losing quality and growing quality gap of psychiatric hospitals. To resolve that problem, Korean Ministry of Health and
Welfare will start psychiatric hospital evaluation and public disclosure program at 2013. Our objective is developing
psychiatric hospital quality indicator system which reflects psychiatric hospital's circumstances and characteristic to
prepared evaluation.
The study was conducted in two stages. First, we conducted indicator reviewing, expert consulting and site visiting.
Second, a consensus-building technique, the expert Delphi survey, was used with nominated participants from four
groups of stakeholders; hospital evaluation expert 2, member of council for psychiatric hospital 2, psychiatrist 3 and
university professor 3. Ten stakeholders participated in two rounds of questionnaires. Each round of questionnaires
included quantitative and qualitative component, a quantitative component about indicator's representability and propriety
by rate on scale of 1-9, a qualitative component offered the opportunity to proved additional feedback in the form of
written comments. Second rounds built on responses to the former round; his or her own score and total distribution on
each indicator, and comment summary. Consensus was defined as being reached when 7-9 score are more than one-half
in each indicator.
We selected 61 indicators through first step which categorized by 3 perspectives; structures, processes, outcomes.
Structures are composited human resources (9) and facilities (21). In processes, there are 29 indicators; patient's human
right (18), clinical performance (11). Outcomes have 2 indicators; readmission rate and length of stay. The Delphi method
reduced the list to 49 indicators rated as essential. As a result, Processes and outcomes are considered important, but
structures are not a main concern. However, in Korea, there are few hospitals which meet the structure requirements.
Among top scored 12 indicators, 6 are in human right. Another are distributed in clinical performance (1), outcomes (2),
facilities (2), and human resources (1). Fewer than 50% scored 12 indicators are facilities (6), human resources (4) and
human right (2). Most of low scored indicators are about safety equipment and staff’s convenience. In 2011-2012, we will
conduct pilot project by using quality indicator system that was developed in 2010. Final quality indicator system will be
determined on the evidence of pilot project.
0384
Computerization of frozen section examination for patient safety and turn around time (TAT) reduction
Juhyeok Park, Gheeyoung Choe, Jinhaeng Chung, Haeryoung Kim
Seoul National University Bundang Hospital, Sungnam-si, Republic of Korea
Objective:
Intra-operative frozen section examination is a major emergency examination which provides important guidelines for
decision making during operation. Occasional man-made errors during the process may result in critical patient safety
accidents, and it is difficult to keep a strict quality control program and turn-around time (TAT) management when the
examination is performed in a hand-written manner. We aimed to provide rapid and accurate frozen section examination
results through the development of a ‘Frozen Section Examination Electronic Medical Record (F-EMR)’ program, focusing
on 1) patient safety, 2) TAT and 3) quality assurance.
Methods:
This study was conducted using the F-EMR program from 1st January, 2010 to 21st December, 2010 at Seoul National
University Bundang Hospital, which is a 900-bed teaching hospital.
1. Prevention of patient safety accidents: In order to avoid errors while confirming patient information at reception of the
specimens, the existing clinical information in the electronic medical record (e.g. clinical diagnosis, name of operative
procedure, organ etc) was displayed and matched with the basic patient information on the F-EMR screen. This dual
confirmation system could prevent patient safety accidents by eliminating potential proximity errors in advance.
2. Shortening of TAT: In order to minimize any extra time taken during the examination due to manual log keeping
processes, we designed the F-EMR system so that the necessary data were automatically entered and managed. In
addition, through the real-time monitoring of the data on the F-EMR system, it was possible to prevent any delays in the
examination.
3. Accurate Quality Control: Automatic entering of test data in the F-EMR system could avoid any data omission and
inconsistencies arising from hand-written management. In addition, the test data could be converted into Quality Control
data through this computerized process, allowing for easy quality assurance.
Results:
We examined the number of test cases, proximity errors, average test times, and quality control items, and obtained preand post-improvement results as follows:
1. The prevention rate of patient safety accidents was increased by 87% from 53% to 99%.
2. The test time for frozen section examination was reduced by 133%, from 17 minutes to 13 minutes.
3. The test data accuracy was improved by 54% from 65% to 100%.
Conclusion:
Although it is of the utmost importance that frozen section examinations should provide rapid and accurate results,
occasional errors may occur during the process when performed on a hand-written basis. Through the development of the
F-EMR system, we were able to prevent patient safety accidents, shorten the TAT and also perform regular and reliable
quality control. We therefore hope that efficient management and use of this system, along with its continuous
development, would provide a good substitute to the current hand-written management and a solution for insufficient
human resources.
0386
Measuring Users’ Satisfaction in a Tertiary Psychiatric Unit in Hong Kong
Chi Kin Jackie Fu
Castle Peak Hospital, Tuen Mun, Hong Kong
Although feedback from clients provides important information for service planning, to obtain an accurate assessment of
patients’ satisfaction in a psychiatric setting is not an easy task. Results might be confounded by the very nature of their
illnesses, the mental state as well as the side-effects of treatment. How these factors affect patients’ perception of
satisfaction and in turn their adherence towards service have further been impeded the lack of a validated instrument in
measuring satisfaction.
Objectives
The current study aimed at filling the void by validating and culturally adapting an existing psychometrically sound
satisfaction survey for the psychiatric patients in Hong Kong, with particular focus on how satisfaction would be affected
by the nature of psychiatric illnesses.
Methods
Focus groups were arranged to obtain patients’ consensus on the concept of satisfaction to hospital services. The
Perceptions of Care questionnaire (PoC) was chosen from literature for translation and back-translation by independent
linguists. The translated Chinese PoC (C-PoC) was evaluated by an expert panel for face content validity.
Participants were patients of age 18 to 65 years consecutively admitted to the Castle Peak Hospital, excluding those with
a diagnosis of mental retardation, dementia or any organic mental disorders. They went through a naturalistic in-patient
treatment until they were discharged. In order to exclude those patients with extended stay at the hospital, only those
leaving the hospital within 31 days of admission were interviewed. Psychiatric symptoms were rated using Brief
Psychiatric Rating Scale (BPRS), Hamilton Rating Scale for Depression (HAMD) and Hamilton Rating Scale for Anxiety
(HAMA). Patients receiving antipsychotic treatment were assessed for side effects by Extrapyramidal Symptom Rating
Scale (ESRS). They also completed self-rated instruments including C-PoC, The Chinese version of Admission
experience survey (C-AES) and World Health Organization Quality of Life Measure (abbreviated version; WHOQOLBREF).
A Confirmatory Factor Analysis (CFA) was performed to evaluate the factor structure of the C-PoC. Correlation between
subscales of C-PoC, WHOQOL-BREF and C-AES served as the theoretical basis to establish the construct validity.
Linear regression was used as a secondary analysis to identify significant factors that might have influenced patient’s
satisfaction.
Results
The C-PoC demonstrated several important psychometric properties of a successful validation, including satisfactory
internal consistency and test-re-test reliability, a four-factor structure that corresponded to the original scale, sound
construct validity as revealed by the significant correlations with quality of life and negative pressure measures. However,
linear regression revealed that BPRS score was negatively correlated with the “global evaluation of care” subscale. The
other three subscales with more objective items were not influenced by psychotic symptoms.
Conclusion
The C-PoC is a psychometrically sound translation of the original scale. However we questioned about the confounding
effect of psychotic symptoms over patients’ subjective satisfaction towards service. We suggest that measuring the
satisfaction of psychiatric patients especially those with psychotic symptoms should employ instruments with objective
variables.
0391
Option of ‘No Sedation’ for Babies in Nuclear Medicine – Continuous Quality Improvement (CQI) Project
1
2
1
1
Kin-Hung Poon , Leung-Kin Kwok , Samantha PS Li , Yuk-Kam Chan
1
2
Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Hospital Authority, Hong Kong, Department of
Nuclear Medicine, Tuen Mun Hospital, Hospital Authority, Hong Kong
Objectives
To promote ‘No Sedation’ for static radionuclide scans via CQI Focus-Analyze-Develop-Execute (FADE) cycles.
Methods:
Traditionally infants were fasted and sedated for certain radiologic procedures in our hospital. However, overseas
guidelines (see reference below) advised that infants below 4 months old may undergo painless radiologic procedures fed
and without sedation. This project began in June 2007.
Pilot runs of ‘No Sedation’ preparation were done for DMSA (Dimercaptosuccinic acid) renal scan since October 2007 and
subsequently for neonatal thyroid scan since November 2008. A feeding room was designated in Department of Nuclear
Medicine (NM). CQI team coaching, written consent, written instructions and clinical pathways assisted implementation.
Parents were still allowed to choose but ‘No Sedation’ option is promoted as best choice in general.
From November 2009, it became routine practice and only verbal consent is needed. The preparation procedures are
posted on departmental website. Staff survey was conducted among all 38 paediatric doctors and a sample of 50 nurses
(10 per ward) to assess understanding in September 2010.
Results:
All cases succeeded. Parents and staff were satisfied with the arrangement.
DMSA scan (7/ 2008 – 6/2010, 24 months): n = 28; ‘No Sedation’ cases = 17 (60.7%)
Thyroid scan (11/ 2008 – 6/2010, 20 months): n = 12; ‘No Sedation’ cases = 10 (83.3%)
Comparing to baseline of 0% without sedation, ‘No Sedation’ promotion makes dramatic change in practice (Figure).
There is reduction in sedation risks, drug costs, staff time in escort, monitoring, documentation, explanation of drugs’ side
effects, administering drugs and handling of complications.
Survey showed all clinicians were aware of this option although some thought that it may be applied in other NM scans.
Table: Summary of staff survey 2010 on understanding of the new approach to patient preparation
Assessed item
% Doctors (no.)
% Nurses (no.)
Awareness of the ‘No Sedation’ option
100%
100%
Knowing this option for DMSA scan
92% (35)
96% (48)
Knowing this option for thyroid scan
79% (30)
80% (40)
Thinking (wrongly) that this may be applied in other NM scans
45% (17)
34% (17)
Conclusion:
‘No Sedation’ option is well accepted, effective, safe and cost-saving. About 30 cases annually may be exempted from
routine sedation. If our practice may be utilized throughout all public hospitals, hundreds of babies will benefit annually.
Wider application is possible, e.g. CT scan and MRI scan when ways to reduce fear of failure are devised.
Reference:
Scottish Intercollegiate Guidelines Network Safe Sedation of Children Undergoing Diagnostic and Therapeutic
Procedures 2004 (No. 58, being revised, http://www.sign.ac.uk/guidelines/published/index.html ).
Figure: Prevalence of ‘No Sedation’ practice for DMSA scan and neonatal thyroid radionuclide scan by 6/2010
'No Sedation' vs 'Sedation' for DMSA Renal
Scan or Thyroid Scan for Babies < 4 Months
100%
80%
60%
Sedation
No sedation
40%
20%
0%
DMSA
Thyroid
0394
Analysis of the accredited continuing education activities in Andalusia related to prevention of central venous
catheter related-bloodstream infections
Francisco Javier Munoz-Castro, Eloisa Valverde-Gambero, Marta Vazquez-Vazquez, Laura Villanueva-Guerrero
Andalusian Agency for Healthcare Quality (ACSA), Seville, Andalusia, Spain
Objective:
To analyze the development of accredited education activities related to Patient Safety Strategy, specifically to prevention
of central venous catheter related-bloodstream infections (BacteriemiaZero project).
Methods:
1. Object of study: Continuing education activities accredited by the Andalusian quality model.
2. Scope: Education related to BacteremiaZero project.
3. Study period: November 2003 - December 2010
4. Sample size: 1,563 accredited activities related to security strategy, 243 of which are related to BacteriemiaZero
project.
5. Design model: Comparative analysis of characteristics (modality, typology, target groups, quality of design,
training opportunities and teaching hours) of continuous education activities accredited by the Andalusian
accreditation model (2003-2010), related to BacteriemiaZero project.
Only those activities that have used in its application for accreditation at least one of the following keywords, have
been taken into consideration: “Bacteremia, Zero”, “Venous catheter”, “Central catheter”, “Dr. Pronovost”, “Central
venous catheter related-bloodstream infections”, “BRC (catheter related-bloodstream infection)”, “Nosocomial
infection”, “Nosocomial”.
6. Instrument: Data were extracted from the database of the web application Me_jora F. Through this tool, training
providers apply for the accreditation of their education activities. The Accreditation program of continuing
education for healthcare professions was launched by the Andalusian Agency for Healthcare Quality in 2003.
The Andalusian Healthcare Ministry implemented the “Patient Safety Strategy” in 2006. This strategy sets out the
guidelines established by the World Health:Patient identification, Safe practices in surgery, Hand hygiene,
Reporting and learning system, BacteremiaZero, Falls prevention, Communication during hand-over, Safe
medication practices.
In order to promote the implementation of this Strategy, several initiatives have been launched, such as the
Andalusian Patient Safety Observatory and the promotion of continuing education.
Results:
The most frequent education activities related to BacteriemiaZero project, are face-to-face or blended courses, followed
by face-to-face workshops. The total amount of accredited activities within this safety initiative is 243, with a total of 885
calls, more than 30,000 training opportunities and 14,000 teaching hours. The average qualitative component is 1.92, the
maximum being 2.8. Training on this topic is mainly aimed at nurses (75%) and doctors (59%).
Activities related to BacteriemiaZero project are 15.6% of total activities related to patient safety.
Conclusions:
To develop training activities related to BacteriemiaZero project, courses and workshops with a high level of practical
methodology are mainly chosen.
Principal beneficiaries of this training are two of the main groups in the Andalusian Healthcare System (nurses and
doctors). From a qualitative point of view, the design of training related to this safety line has higher quality than
educational activities related to other subjects (1.92 vs. 1.81).
We understand that training related to BacteriemiaZero project promotes the development of the Patient Safety Strategy.
On the other hand, it would be desirable to extend this training to other groups of healthcare professionals (nursing aides,
orderlies, vocational training technicians, etc.).
0395
Re-alignment of Occupational Therapy Service to Improve Quality of Care for Orthopaedic Patients
Winnie Fok, Jo Wong, Y T Au Yeung, Jospeh Poon
Tuen Mun Hospital, Hospital Authority Hong Kong
Objective:
To improve the quality of Occupational Therapy Service to orthopaedic patients in Tuen Mun Hospital.
Methods:
In Tuen Mun Hospital, Occupational Therapy Service for acute, rehabilitation in-patients, general out-patients versus
specialized hand rehabilitation under orthopaedic specialty were taken care by two separate teams. In July, 2009, a
comprehensive service review was performed in terms of manpower, patients ‘attendance, triage and first attendance
waiting time. As revealed from the value stream mapping and root cause analysis, the new upper limb out-patients who
were more ad hoc in nature and required immediate assessment and triaged intervention was the major cause of wastes
in waiting time and staff transportation. This subsequently led to prolonged triage waiting time for new patients, disruption
in work flow and decreased treatment intensity for both in and out patients. To improve the condition, services were
restructured in October 2009. The Hand Team took over the upper limb orthopaedic out-patients and provided more
timely but equally effective intervention. The Orthopaedic Team could thus be more focused to handle the other patient
groups.
Results:
Work flow and volume were reviewed one year later. The out-patient triage waiting time decreased from 40 to 24 minutes
(-40%) and the staff transportation time reduced from 50 minutes to 30 minutes (-40%). The staff time saved led to an
increase in throughput. With same manpower, in-patient follow up attendances increased from 612.1 to 1576.5
(+157.5%), out-patient follow up attendance increased form 576.3 to 736.3 (+27.8%). Waiting time of new out-patients
decreased from 0.64 week to 0.56 week (-12.5%). Therapists also reported better subjective well-being with less fatigue
and frustration.
Conclusion:
Through this exercise, we have achieved better service quality in terms of shorter waiting time, improved efficiency and
more intensive treatment program for both orthopaedic in- and out-patients. Both patients and staff benefited.
0396
The importance of aligning registries monitoring quality and safety with nationally endorsed Operating Principles
for Clinical Quality Registries.
Sue Evans, Jeremy Millar, Julie Wood, John McNeil
Monash University, Victoria, Australia
Objective: To explore the feasibility of establishing and operating a clinical quality registry in line with Australian
nationally endorsed Operating Principles for Clinical Registries.
Methods: Clinical quality registries collect health-related information on individuals who are treated with a particular
surgical procedure, device or drug, diagnosed with a particular illness, or managed via a specific healthcare resource.
They are increasingly seen as a keystone to improving the safety and quality of care. The Prostate Cancer Clinical
Quality Registry (PCR) is a population-based registry established in 2009 to monitor quality of care provided to men
diagnosed with prostate cancer and collects diagnostic, treatment and outcome data from 35% of newly diagnosed
prostate cancer cases in Victoria. The PCR collects and reports on ten clinical indicators.
Operating Principles for Clinical Quality Registries (“Operating Principles”) were formally endorsed by the Australian
government in 2010 following a consultation process with registry custodians and the wider community by the Australian
Commission on Quality and Safety in Health Care. They set out 41 principles under which clinical registries should
operate. We assessed compliance of the PCR with the Operating Principles. Where gaps existed, strategies were
developed to address them.
Results: Attributes: The Operating Principles state that data collection should use identical methods across all sites. We
identified that IT issues (a time lag in cancer notification) precluded us from aligning with this principle. We have
scheduled periodic data validation checks to ensure complete patient recruitment using an alternate recruitment approach
in two sites.
Data collection: The Operating Principles state that standard definitions, terminology and specifications should be used to
enable meaningful comparisons to be made and to allow maximum benefit to be gained from linkage to other registers
and other databases. Some data items were not defined in the (Australian) National Data Standards (METeOR) and for
these we used international definitions and wrote submissions to include data items in METeOR. The format of a number
of data items was changed to align them with METeOR. The Operating Principles state that to avoid duplicating data
capture, registries should use data from existing data sources where they are of a satisfactory quality. We explored autopopulation technology and identified cost ramifications of using this approach in each recruitment hospital.
Data elements and risk adjustment: The PCR collects identifiable information, clinical indicators and covariates required
for risk adjustment. Outcomes are adjusted to take into account the risk of disease progression. However, no reliability
testing had been undertaken to ensure that data was consistently collected by data collectors. Test-retest reliability testing
has been scheduled on a random sample of cases.
Data security: The PCR is housed in a secure facility with password access. However, it does not comply with the
Technical Standards ISO 27001 and 27002 and is being addressed as a two-year work program.
Organisation and governance: The Operating Principles state that formal governance structures must exist with a plan to
address outliers or unexplained variance. The PCR has developed statistical processes to identify outliers and an
escalation policy.
Data custodianship: The Operating Principles state that custodianship must be made explicit and that data access and
reporting policies must be made available to people wishing to use registry data. We identified numerous legal issues
associated with ‘ownership’ of information and responsibilities of Steering Committee members which require clarification.
Conclusion: All clinical registries should undertake the process of assessing compliance with Operating Principles. It has
highlighted gaps and enabled strategies to be developed to ensure data integrity. This will provide reassurance to
clinicians that data being used to monitor quality of care is accurate and complete.
0398
Implementation Results of Post-buccal Cancer Surgery Care Education
SHU-WEN CHENG, Fang-Hua HSU, Pei-Yin LIAO, Chia-Chi KUO
Chi Mei Hospital, Tainan, Taiwan
Objective:
Implementation of accurate oral care for post-buccal cancer surgery patients will promote healing, lower the chances of
infection, and ensure that patients are in a comfortable state. This project aims to promote the accuracy rate of education
for post-buccal cancer surgery care.
Methods:
The work team adopted the quality consciousness reinforcement strategy and implemented an improvement project
during the period from August 1 to October 31, 2009:
1. Establish post-buccal cancer surgery care indicators: the team set up the "Checklist of Oral Cleaning for Post-buccal
Cancer Surgery", "Monitor Chart of Oral Care for Post -buccal Cancer Surgery", the indicator threshold, and the
assessment/ improvement mechanism.
2. Develop oral care seed specialists: this project trained three delegated oral care nursing specialists, in charge of
consultation, patient check-up, and indicator monitoring.
3. Conduct "Post-buccal Cancer Surgery Care Indicator Seminar": the project team hosted two seminars on September
20 and October 3, 2009. The full staff of 18 nurses participated in this event. The seminar covered several topics,
including introduction to the indicators, demonstration of how to use the "Checklist of Oral Cleaning for Post-buccal
Cancer Surgery", and the standards of Oral care. Pre- and post-test on implementation of oral care have also been
conducted.
Results:
1.
After the "Post-buccal Cancer Surgery Care Indicator Seminar", the score of the nursing staff’s cognition on oral
care increased from 55 to 90 and the accuracy rate of oral care education was raised from 16.7% to 100%.
2.
From January to December 2010, a total of 25 cases were admitted for indicator surveillance, and the average
accuracy rate of Oral care education was 92%. The cases of incorrect consultation were immediately rectified under
the supervision of the delegated nursing specialists. This shows that the goal of this project has been achieved.
Conclusions:
The results show that intervention of the post-buccal cancer surgery care consultation project effectively uplifted the
nursing staff's cognition on oral care and the accuracy rate of the oral care education. The target institution is planning to
implement regular monitoring of the "Post-buccal Cancer Surgery Care Indicator".
0402
Implementation of a model for management of individual development plans in the Health Care System of
Andalusia
Mayte Periañez, Thomas Espósito, Joaquín Navarro, Javier Ferrero
Andalusia agency for healthcare quality, Seville, Andalusia, Spain
Objective:
To construct individual itineraries of learning that respond to the needs of acquisition or strengthening of competences of
each of the professionals of the Health Care System of Andalusia (SSA), generating an impact in professional
development and in the organization.
Methods:
Among the functions of the Quality Observatory for Health Care Training is the designing of training policy development
initiatives in key skills, development and innovation in teaching methods and the use of training resources adapted to the
needs of the different health professions.
To perform these functions, the Quality Observatory has designed a model for management of individual development
plans (GPDI) which starts from the reflection of the professionals in relation to their initial level of qualification with respect
to specific practices (good practices). In order to facilitate this management, a Web-tool has been developed that allows
the online construction of training and improvement requirement plans.
The GPDI model is composed of the following phases:
1. Configuration of type maps for each job.

Identification of key skill and specific practices

Requirements associated with each practice for each level of development (low, average, high and very high).

Objectives related to each specific practice.
2. Generation of individual maps: adaptation of the type map to the professional.
3. Self-evaluation: positioning of the professional in each practice according to their level of development.
4. Configuration of the individual and group competence profile for the job.
5. Detection of the competences gap of the professional and of the group of professionals of every job.
6. Construction of the individual development Plan: automatic prioritization of practices with greater need of development
or training for each professional.
7. Proposal of a training needs Plan for departments or services
8. Construction of the training needs plan for the organization.
9. Design of tailored training programmes
The GPDI tool has been designed for a decentralized, interactive and independent management by the care units. The
tool favours the exchange of corporate knowledge, when sharing information.
Results:
The implementation of the GPDI model was piloted for 6 months during 2010, in 24 hospital and primary care
organizations, and in a total of 62 care units and 24 training units.
Participating in this pilot experience were 24 unit directors and 380 professionals, who already have their individual
development plans.
Also, the average competences profile of the directors of Clinical Management Units was obtained, the greater
deficiencies being found in practices related to communication in crisis situations, and to the boosting of teaching and
research, for which training programmes have been specifically tailored.
New key skills have been identified within the Clinical Management Units and functional units, and the location of those
professionals with greater levels of development in specific practices has been detected.
Conclusions:
The construction of plans of development needs adapted to the improvement of individuals and groups, through training
prioritized by the learning itineraries, allows the evaluation of the impact of the training in the development of the
professionals, the organization and the attention to the citizen.
The GPDI model allows the implementation of new modalities and typologies based on shared learning.
The pilot experience has also favoured the detection of new functionalities in the Web-tool by the professionals who have
participated in it, leading them to become more competent in the process of the management of individual development
plans.
0404
Outcome improvements after implementation of an outcome-driven quality management system – Analysis on
the hospital level
1
1
2
3
Thomas Mansky , Ulrike Nimptsch , Wolfgang Krahwinkel , Oda Rink
1
2
3
Technische Universität Berlin, Berlin, Germany, HELIOS Krankenhaus Leisnig, Leisnig, Germany, HELIOS Kliniken
GmbH, Berlin, Germany
Objective: Evaluation of changes of in-hospital mortality for common medical treatments on the hospital level after
implementation of an outcome-driven quality management system.
Methods: We studied data of 11 German acute care hospitals which have been acquired by the private for-profit Helios
hospital group between 2004 and 2006. We set the year of acquisition to be the starting point of implementing the quality
management system developed by the Helios hospital group. The Helios system relies on measuring outcome indicators
based on readily available administrative data, peer reviews to analyze and improve treatment processes and publishing
of results. Newly acquired hospitals are immediately integrated into the Helios quality management system via the new
administration and help by peers of other Helios hospitals. Targeted peer reviews are performed by specialists from other
Helios hospitals in departments showing subpar results.
We studied annual in-hospital mortality 1 year before and up to 4 years after acquisition for myocardial infarction,
pneumonia, stroke and heart failure. To address possible differences and changes in case-mix in-hospital mortality has
been indirectly standardized by sex and age group according to the German average of the respective calendar year. Inhospital mortality is represented by the standardized mortality ratio (SMR, quotient of observed and standardized
expected mortality). The target set by Helios is to achieve mortality rates below the German average.
Results: For myocardial infarction one year before acquisition 5 of 11 hospitals had a SMR above 1 (that is, a higher rate
of in-hospital mortality than the German average). Those were mainly hospitals with low volumes of myocardial infarction
treatment. SMRs of these hospitals ranged between 1.1 and 1.7. One year after acquisition there were 3 hospitals with a
SMR > 1 left (range 1.1 – 1.5). Three years after acquisition only one hospital had a SMR of 1.1, all other hospitals
performed well with SMRs between 0.4 and 0.9.
For stroke 6 of 11 hospitals had SMRs above 1 (range 1.2 – 1.6) one year before acquisition. Three years after
acquisition there were 2 hospitals left above the German average (SMR 1.2 and 1.3).
For pneumonia, all 5 of 11 hospitals performing subpar one year before acquisition (SMR 1.1 – 1.6) reduced their inhospital mortality to below the German average within three years after acquisition.
Heart failure mortality has been above the German average in 3 of 11 hospitals one year before acquisition. Three years
after acquisition there was only one hospital left with a SMR of 1.7 which could not improve results until four years after
acquisition.
Conclusions: Rapid improvements could be achieved in myocardial infarction and pneumonia treatment. Outcome
improvements for stroke or heart failure seem to take a little more time in some hospitals. Assessing and monitoring
outcome indicators on the hospital level using available administrative data helps to identify quality problems and to
initiate targeted peer review procedures. Findings of these peer reviews most often concern problems related to guideline
adherence, organizational responsibilities and interdisciplinary teamwork, which are known to effect outcome. Based on
these findings mandatory agreements on corresponding improvement activities are concluded with both, local physicians
and the hospital’s CEO. The success (or failure) of these activities can then be monitored by continuous outcome
measurement. If necessary, additional actions may be taken for improvement. This quality management system is highly
effective in improving outcome in hospitals having subpar results.
……………………………………………………………………………………………………………
Busse R, Nimptsch U, Mansky T (2009) Measuring, Monitoring, And Managing Quality in Germany’s Hospitals. Health
Affairs 28 (2): w294-w304
Mansky T, Nimptsch U, Vogel K, Hellerhoff F (2010) G-IQI – German Inpatient Quality Indicators. Universitätsverlag der
TU Berlin, urn:nbn:de:kobu:83-opus-26102
Peterson, ED et al. (2006) Association Between Hospital Process Performance and Outcomes Among Patients With
Acute Coronary Syndromes. JAMA 295 (16): 1912-1920
0405
INCREASING ACCESS TO BIRTH SPACING INFORMATION FOR MARRIED COUPLES IN NORTHERN NIGERIA
Samaila Yusuf, Tunde Segun, Emmanuel Otolorin
Jhpiego, Kano State, Nigeria
A high unmet need for birth spacing methods of contraception in Northern Nigeria is depriving majority of married and
eligible couples from the benefits of the influence of well-spaced births on maternal and child health. The ACCESS project
was designed to promote the use of birth spacing methods through trained Female Household Counselors and Male Birth
Spacing motivators at the community level in 79 villages of the 4 LGAs across Kano and Zamfara States. The study
objective is to determine the extent to which interpersonal counseling and education approach used has made explicit
efforts to improve the access of contraceptives for men and women in Northern Nigeria. Community informant
interviewing was the primary method used for obtaining data, supplemented with information from the routine program
monitoring system and community directed intervention questionnaires used in the ACCESS end line survey.
The main results were marked increase in the current use of birth spacing methods among married women with 67
women out of 444(15.1%) reporting that they were using a method at the time of the end line survey, up from 5 out of 390
women (1.2%) at baseline. Joint decision making about family planning use for both wife and husband was 19.4% at
baseline and doubled at end line to 37%. The household counseling by both the female Counselors and male birth
spacing motivators has demonstrated that scaling up BCC/Community Mobilization activities to increase access of
married couples to family planning can reduce barriers to unmet needs.
0407
Evaluation of an Innovative e-Health Technology in ICU by the Users
KW Lam, CL Lam, Kelly Choy, KY Lai
Queen Elizabeth Hospital, Hong Kong
Objective
Evaluation of an innovative e-health technology, Clinical Information System, in the Intensive Care Unit of Queen
Elizabeth Hospital from the users' perspective
Methods
In order to support the efficient patient-centred care in ICU, we modernized the service delivery with innovative e-health
technology. We initiated the installation of computerized Clinical Information System (CIS) in our ICU in 2009. It leads to
improvement in the quality of care and patient safety by reducing the medical errors.
In 2010, we conducted a survey to evaluate the system and service quality as well as the satisfaction by the staff in ICU
using CIS. It examined the views and altitudes of the respondents on the CIS. There were 5 questions on "perceived ease
of use" and 6 questions on "perceived usefulness". The questions on “perceived ease of use” were: (1) CIS is easy to use,
(2) Interaction clear and understandable, (3) CIS is easy to learn, (4) Easy to be skilful, (5) Flexible to interact. The
questions on “perceived usefulness” were: (1) CIS improved work effectiveness overall, (2) CIS improved quality of care
in workplace, (3) CIS improved record maintenance overall, (4) CIS accomplish task more quickly, (5) CIS maintains
confidentiality better than paper, (6) System is useful. There were 7 scores for each question: (1) Strongly disagree, (2)
Disagree, (3) Mildly disagree, (4) Neutral, (5) Mildly agree, (6) Agree, (7) Strongly agree and the respondents chose a
score for each question.
The mean scores for each question were calculated. Student's t test was employed to detect any significant trend in the
respondent's attitudes about the usefulness and ease of use of the CIS. We tested whether the mean score for each
question was different from the score of 3 which represented a response that CIS was inferior to existing system.
Results
A total of 73 survey forms were returned. Fifty respondents were female and 21 were male. Fifty seven were nurses, 10
were nurses, 1 was allied health staff and 1 was clerical staff.
The respective mean scores of each question for “perceived ease of use” were as follows: (1) 4.38, (2) 4.30, (3) 4.45, (4)
4.32, (5) 4.11. The respective mean scores of each question for “perceived usefulness” were as follows: (1) 4.49, (2) 4.22,
(3) 4.75, (4) 4.21, (5) 4.11, (6) 4.59. The difference of the mean scores of each question from 3 was highly significant by
student's t test (p<0.001). The results showed that the respondents regarded CIS as useful and easy to use compared to
existing system and it reached statistical significance.
Finally, they were asked whether they preferred CIS or paper based system. Fifty-three percent of respondents chose CIS,
32% were neutral and 15% preferred paper-based system.
Conclusion
With careful planning and adequate support, implementation of innovative e-health technology in ICU is feasible and it
improves the quality of service and patient safety. They were regarded by users as easy to use and useful. The
acceptance of innovative e-health technology by users was high as shown by the result of our study that 85% of
respondents were willing to change their practice.
0408
Service Quality Improvement Programme with e-Health Technology in ICU
KW Lam, Leo Cheung, Kelly Choy, KY Lai
Queen Elizabeth Hospital, Hong Kong
Objective
Continuous performance and quality improvement by audit of outcome indicators of ICU service with innovative e-health
technology
Methods
Since 2006, Hong Kong Hospital Authority ICUs have adopted a standard tool for outcome prediction and ICU
performance assessment-the APACHE (Acute Physiological and Chronic Health Evaluation) outcome prediction model. It
has developed a user-friendly computerised system of data collection for automatic capture of physiological and
laboratory data accurately and efficiently. It greatly reduced errors in the data collection due to transcription and human
factors. With such information, each ICU can identify its strengths and the service gaps so that continuous performance
improvement can be achieved. Fourteen ICUs in Hong Kong have participated this programme and it greatly facilitates
service planning leading to improvements in the organization and practice of adult critical care.
Results
The summary reports from 2007-2010 were analysed. There were 835 episodes of ICU new admission in Queen
Elizabeth Hospital in 2007.The mean age of our patients was 59.45 years old. Forty-nine percent of patients came from
operation theatres and 49% came from general wards. About 1.7% of patients were admitted directly from A&E
Department. Forty-four percent of patients were from medical specialty and 37% were from surgical unit. The mean
APACHE IV APS score (which is a reflection of illness severity) was 64. The mean ICU length of stay was 5.38 days. The
hospital mortality was 20.24%. From the baseline data in 2007, the characteristics and outcomes of our patients were
comparable to HA ICUs overall except that we admitted a lower proportion of patients directly from A&E department
(16.7% of ICU admission from A&E department for HA overall). After we had identified the service gap, we implemented
several measures to improve our performance. There was a continuous increase in number of direct admission from A&E
department in subsequent years (10.26% in 2008, 11.15% in 2009 and 10.83% in 2010). It resulted in a marked increase
(> 600%) of direct admission from A&E department from 2008-2010 and the difference was highly statistically significant
by chi square test (p < 0.01).
Conclusions
With the development of innovative e-health technology, it allows the clinicians to obtain useful information in a timely and
accurate manner. It assists in subsequent service planning for improvement of performance and quality. In the future,
Hong Kong Hospital Authority will collaborate with Intensive Care National Audit & Research Centre (ICNARC) of UK for
benchmarking Hong Kong ICU performance with foreign database in order to achieve international standard.
0409
The ascent of work efficiency through improvement of operating system in rehabilitation therapy units(Physical
therapy, Occupational therapy, Speech therapy)
Kyung Ho Kim, Nam-Jong Paik, Yun-Up Koo
Seoul National University Bundang Hospital, Seongmam Si/Bundang Gu, Republic of Korea
Objective
Our rehabilitation units’ problems are as followed:
First, many outpatients are having problems with making an appointment. It not only takes more than 5 days but also they
have to drop by at every single therapy room to make an appointment which bothers patients. Also, the therapists are the
ones who have to deal with the outpatients to make an appointment while they are in a session with the patients.
Secondly, since we have a different medical payment process, the amount of arrears is higher than other departments.
Lastly, we have high number of patients who miss their appointments without any notice which brings the rate of our
therapy result low.
Method
First, we developed a new computer program and have hired an appointment-making receptionist which reduced the time
required for the patients to make an appointment. They, also, could make several appointments only at the reception
quickly.
Secondly, we have innovated the process of "doctor consultation -> reservation for treatment of rehabilitation -> issue a
medical insurance fee(manually done by the desk clerk) -> payment -> treatment" to "doctor consultation -> reservation
for treatment of rehabilitation(simultaneously and electronically issue a medical insurance fee) -> payment -> treatment"
to reduce the amount in arrears. Electronic process decreased the number of errors that have been made before.
Thirdly, we educated patients and their caregivers to call in advance if they cannot attend the therapy session. It let us
identify the day’s schedule without any waiting period. And then we priorize as a below 3-step the patients who should be
treated in blank time.
(Priority list: 1st New inpatients, 2nd New outpatient, 3rd Ward patient)
Results
The ratio of the therapy result (=the number of treated patients/ the number of patients to be able to treated) is increased
from 75.3% to 85%.
And because of the computer program is not developed completely, we could not draw an accurate result. However, we
are expecting the time for our outpatients to make an appointment will reduce from 5-6 days to 1day(immediately after the
treatment prescription). Also, the percentage of the default is expected to decrease rapidly.
Conclusion
Through these processes, we standardize the payment system of medical bills, systematized reservation system for
rehabilitation therapy, and improved the therapy results, which increased the work efficiency and the quality of the medical
service. To maintain current condition, we should, constantly, monitor the three indicators; time for the reservation, the
amount of arrears, and the quality of therapy result. We will try our best to satisfy the patients’ need and maintain its high
quality.
0414
Upgrade the Accuracy and Completion Rate of Nursing Instruction for Post-TUR-P Urinary Incontinence Patients
Chun-Hui Hsiao, Fang-Hua Hsu, Mei-Hwei You, Chia-Chi Kuo
Chi-Mei Medical Center, Tainan, Taiwan
Objective: Urinary incontinence has been a complication that bothers the post-surgery patients of transurethral resection
of prostate (TUR-P). Post-TUR-P care and pelvic floor muscle rehabilitation exercise (PFMR) are helpful to improve the
problem of urinary incontinence. This project aims to upgrade the accuracy and completion rate of nursing instruction for
post-TUR-P patients who are suffering from urinary incontinence.
Methods: The project team conducted an investigation from January to March 2010 and found that the occurrence rate of
post-TUR-P urinary incontinence in urology wards was 14%, and the nursing staff performed an accuracy rate of only
11% and completion rate of 32% in the post-TUR-P urinary incontinence nursing instruction. Through group discussion
and analysis, we found that the problem lies in the nursing staff’s insufficient knowledge in post-TUR-P urinary
incontinence and the shortage of tools for assessment and PFMR instruction. Therefore, the project team designed the
following solutions:
1. Establish a set of post-TUR-P urinary incontinence quantity control indicators, post-TUR-P urinary incontinence
assessment chart, and post-TUR-P urinary incontinence nursing instruction standards and the demonstration video of
PFMR. 2. The project team hosted two post-TUR-P urinary incontinence quality control indicator consensus meetings on
th
th
April 7 and 15 2010. The full staff of 18 personnel participated in this event and the meetings discussed several topics
including an introduction to the quality control indicators, post-TUR-P urinary incontinence assessment and nursing
instruction standards, and an introduction to the PFMR demonstration video. A pre- and post-tests have also been
implemented on the staff.
Results: After the post-TUR-P urinary incontinence quality control indicator consensus meetings, the scores of the
nursing staff’s cognition on post-TUR-P urinary incontinence was raised from an average of 60 to 92, and the accuracy
rate of post-TUR-P urinary incontinence patient nursing instruction was raised from 11% to 100% and the completion rate
from 32% to 100%. This shows that the goal of this project has been achieved.
Conclusions: Results of this project show that establishment of quality control indicators, assessment tools, and nursing
instruction tools helps to raise the accuracy and completion rate of post-TUR-P urinary incontinence patient nursing
instruction. Improvement in the system effectively improves the patients’ urinary incontinence problem; therefore we
suggest clinical institutions to adopt and promote this system.
0417
Using electronic checklist to improve the efficiency of intravenous thrombolytic therapy in patients with acute
ischemic stroke
Chun-Ming Yang, Ping-Jang Kuo, Huey-Juan Lin
Chi-Mei Medical Center, Tainan, Taiwan
Objective:
Improve the efficiency of intravenous (IV) thrombolytic therapy in patients with acute ischemic stroke.
Methods:
We introduced an electronic checklist in the flow chart of IV recombinant tissue-plasminogen activator (rt-PA) therapy for
acute ischemic stroke from August, 2010 to December, 2010. When a patient who was suspected of acute stroke with
onset within 2.5 hours arrived at the triage of the emergent department (ED), the electronic checklist was immediately
activated by the triage nurse. The electronic checklist mainly involved Microsoft Network (MSN) messenger and cell
phone messages. The computers at ED main stations, computed tomography (CT) room, and medical laboratory room
could catch the alarmed MSN messages to set a priority for exams and tests. The same messages were sent by cell
phone to the medical team including ED physicians, duty-neurologist and nurse leader to initiate immediate actions.
During the process at set points, the checklist would automatically remind the team of mandatory procedures and prevent
skipping necessary steps. For performance indices, we calculated the time from arrival to finishing CT scan (door-to-CT)
among potential candidates for thrombolytic therapy, the time from arrival to IV rt-PA (door-to-needle) in patients receiving
the therapy, and the proportion of IV thrombolytic therapy in all ischemic stroke patients. The performance was compared
before (January-July 2010) and after (August-December 2010) the introduction of electronic checklist with Wilcoxon ranksum test as appropriate.
Results:
In total, 136 acute ischemic patients were activated by the electronic checklist for an urgent CT scan. The median door-toCT time were 28 minutes (interquartile range (IQR), 18-39) before the intervention, and 19.5 minutes (IQR, 14-25) after
(p<0.001). There were 23 (3.7%) ischemic stroke patients treated with IV rt-PA before the intervention, and 24 (4.8%)
after. The median door-to-needle time were 74 (IQR, 55-85) minutes before the intervention and 56 (IQR, 45-92.5)
minutes after (p=0.338).
Conclusions:
Electronic checklist significantly shortened door-to-CT time and might consequently improve door-to-needle time. The
system might also facilitate IV thrombolytic therapy in acute ischemic stroke.
0423
Systematic and prospective risk assessment at a university hospital operative room
Jean-Blaise Wasserfallen, André Vagnair, Alessandro Foletti
Lausanne University Hospital (CHUV), Lausanne, Switzerland
Objective
To systematically and prospectively assess risks for patients admitted to the operative rooms (OR) at our university
hospital.
Methods
The work done in the operating room of a set of French hospitals (http://midipyrenees.sante.gouv.fr/santehom/vsv/vigilanc/dossiers/risques/d_final2.pdf) was adapted following the ISO31’000
standard risk management process to the specificities of our hospital. The RMWG was composed of representatives from
the surgeons, the anesthetists (physicians and nurses) and scrub nurses working in the OR.
Risks were classified into 7 main processes along the patient pathway through the OR : admission, installation,
anesthesia, operation, arousal, recovery, and setting up equipment for the next case (resetting).
They were further analyzed, classified and reported into a 4 grade scale consequence/likelihood matrix (maximum score
of 16). Finally, they were ranked into 3 severity categories: under control if the severity score was lower than 4,
intermediate if the score was between 4 and 8, and intolerable if the score was higher than 8.
A second classification was carried out along the WHO event (incident) taxonomy for patient safety.
Results
A total of 131 different risks were identified. Their distribution in the different processes and by severity categories is
displayed in the table below.
Admission
Installation
Anesthesia
Operation
Arousal
Recovery
Resetting
Number of
risks
14
28
12
48
12
4
13
Under
control
(50%)
11
15
7
18
9
3
10
3
9
5
21
3
1
3
0
4
0
9
0
0
0
Intermediate
(40%)
Intolerable
(10%)
According to the WHO event (incident) taxonomy for patient safety, the three most common types of events were related
to : medical device/equipment (27%), clinical processes/procedures (23%), and patient accidents (13%). By decreasing
order of severity, the first three events were related to: resources/organizational management (severity score = 16), staff
factors (severity score = 12), and medical device/equipment questions (severity score = 9).
Combining the 2 different approaches allows focusing priority on these 3 types of events during the installation and
operation processes.
Conclusions
Systematically and prospectively risks analysis and mapping for patients admitted to the OR is possible and useful. As a
decision-making tool, it allows prioritizing risks to be addressed by improvement measures to bring them under control, as
well as regularly assessing residual risk once corrective and preventive measures are taken. It should be used in
conjunction with a critical incident reporting system, which will help assessing whether taken measures are effective.
0424
Patient recall after misuse of a bloodletting instrument at an outpatient clinics
1
1
2
1
Jean-Blaise Wasserfallen , Giorgio Zanetti , Philippe Staeger , Lucia Mazzolai
1
2
Lausanne University Hospital (CHUV), Lausanne, Switzerland, Lausanne University Medical Policlinics (PMU),
Lausanne, Switzerland
Objective
To identify what measures should be implemented to recall patients after a patient-use bloodletting instrument was
misused with several patients at an outpatient clinics in a university hospital.
Methods
A task force was set up, composed of representatives from the medical and nursing direction of the hospital, specialist in
infection control, and physicians and nurses from the outpatient clinics. The number of patients potentially exposed to
blood contact was identified, and a process for internal and external communication singled out. A procedure to contact
the patients, organize the consultation, blood analyses and communication of results was established, including ways to
deal with unexpected reactions from both medias and patients.
Results
A total of 280 patients were considered for recall. Of these, 263 patients (94%) responded to the invitation to be tested,
and 218 (82.9%) had negative test results ; 38 (14.1%) healed hepatitis B (of which 18 were already known); 5 hepatitis C
(2%, of which 4 were already known) ; and 3 (1.1%) both infections (all already known). Seventeen patients (6%) could
not be tested (9 patients had died in the interval ; 5 patients refused to be tested ; 2 patients could not be contacted ; and
1 patient lived in a country where testing was not possible).
Except for one patient who claimed that her hepatitis B was acquired during this event, which was proven impossible by
the sequence of events, all tested patients accepted that such an error could occur and submitted to testing and
communication of results without difficulty. It implied however an important investment from the clinicians and laboratories
involved in the process.
Conclusions
Recalling patients after an error in a process of care is possible though difficult to carry out. Patients had a surprisingly
good acceptance of the whole process and understanding that such an error could occur. Given the low yield of positive
results, the usefulness of such a procedure in this kind of situation should be carefully assessed before launching it.
0428
Epworth Eastern Excellence – We Can Make a Difference
Lisa Edwards, Louise O'Connor
Epworth HealthCare, Richmond,Victoria, Australia
Patient outcomes are often improved if they are aligned with the goals of their care. One of the aims of Epworth Eastern’s
Excellence program is to ensure that the patient’s perception of care is enhanced due to their inclusion from the beginning
of their admission to the desired outcome. The focus was on care, compassion and consistency. This was a whole of
hospital initiative, and multidisciplinary in its approach. Several key elements were introduced to Nursing staff and are
nd
required to be met every hour during the day and 2 hourly overnight. These elements focus on patient safety and
improved communication with the patient. These are called the 3P’s and 4R’s:
• Pain – evaluate the patient’s level of pain and give appropriate pain relief and make them comfortable.
• Potty – offer to take the patient to the toilet.
• Position – change the patient’s position, ask whether they are comfortable and provide pressure area care.
• Rx – provide any needed medication and inform the patient of any treatments they may require.
• Reach – ensure the patient’s essential needs (call bell, phone, water jug, reading material) are within easy reach.
• Respond – ask if there is anything else the patient needs or if they have any questions. Listen carefully and respond
to any concerns the patients may have.
• Reassure – express care and concern during your visit and remind the patient that you will check on them again in an
hour.
Following hourly rounding with the patient the legacy of the conversation resonates on the whiteboards in each of the
patient’s rooms and provides a constant reminder of what the agreed goals for the day are, pain management targets and
list the staff caring for the patient on that day.
Hourly rounding actions are captured electronically via touch screen terminals in each patient room. These terminals
provide point of care clinical applications thus improving patient interaction to their care plan and access to pathology,
radiology and ePrescribe (electronic medication chart) and validation that hourly rounding has occurred. Hourly Rounding
can be monitored at central Nurse’s station and Nurse Manager’s office. This summary log provides the ability for
Managers and senior staff to monitor real time activity; seek to improve our ability to effective hourly round and ensure
that patient’s needs are met and safety maintained.
Results:
We are still on our journey of effective hourly hounding and to date we have seen the following improvements in both
patient safety and patient perception of care:
•
•
•
•
Falls have reduced by over 40% - this reduction in falls has been over a period of time where inpatient occupancy has
increase from 79% to over 90% in June 2010
Call bells and average response times have significantly reduced with one Ward experiencing a reduction of over
1500 call bells per month
Press Ganey Patient satisfaction surveying indicates a gradual incline is results for two key questions – nurses kept
you informed and nurses effort to include you in decisions. Achievement includes the following for our cardiac unit:
th
nd
o From 30 percentile to 72 percentile for how nurses kept you informed
th
nd
o From <10 percentile to 92 percentile for nurses effort to include patients in decisions
th
th
Overall patient experience according to Press Ganey surveying has risen from <10 percentile to the 55 percentile
Conclusion:
The Epworth Eastern- We Can Make a Difference program has achieved its first goal – it has made a difference. The
objective now is to sustain the difference that we are making and continue to provide exceptional service to all our
patients. Whilst we do show care and compassion our next goal is the consistency and to achieve this ALWAYS.
0429
Get behind it! Taking the pressure off in the Emergency Department.
Katrina Cubit, Bernadette McNally
Calvary Health Care ACT, Canberra, Australian Capital Terriroty, Australia
Objective - To reduce the prevalence of sacral pressure injuries caused by friction, shearing and excess moisture in older,
higher risk patients admitted via the Emergency Department (ED) with a medical condition
Method - The project comprised three phases. Phase 1 focussed on educating nursing staff in both the ED and on the
medical wards on pressure injury assessment, management, documentation and dressing product knowledge. Pressure
injuries were graded using the system approved by the Australian Wound Management Association.
Phase 2 involved patient recruitment. All patients 65 years or over with a medical condition presenting to the ED,
classified as being at ‘high’ or ‘very high’ risk of developing a pressure injury (Waterlow score >15) were approached to
have a sacral dressing applied along with the usual pressure injury prevention plan. Patients who presented to the ED
with a sacral pressure injury were excluded from the study and their pressure injury managed as per the Calvary Health
Care ACT Policy, Procedures and Guidelines.
In Phase 3, nursing staff undertook sacral skin checks on the participants three times every 24 hours by lifting the
dressing away from the intact sacral skin. The dressing was reapplied on completion of assessment. The dressing was
changed every 3 days or when soiled. All observations were documented on the specially developed data collection form.
The development of any pressure injury was documented and reported in the RiskMan electronic incident reporting tool.
Data was collected from Riskman, and via a clinical audit of the nursing notes and data collection form.
Results - During the 61 day recruitment period, 186 patients aged over 65 years were admitted to hospital via the ED
who met the criteria for the project. A total of 77 patients were excluded. Of the possible 109 patients meeting the
inclusion criteria, 51 consented to participate. The remaining 58 patients were retrospectively allocated to the pseudo
control group.
Of the 51 patients consented to participate in the study, 19 were male and 32 were female, with an age range of 65 to 96
years (mean = 82.0 years). Patient’s length of stay ranged from 1 to 68 days (mean = 15.2 days). Eighteen (35%) of the
patients admitted via ED had a respiratory condition, followed by coronary disease (14%), falls (12%), infections (10%)
and gastrointestinal problems (7%).
A total of 58 patients were allocated to the pseudo control group. There were 27 male and 31 female patients with an age
range of 65 to 95 years (mean = 82.0 years). Length of stay in the control group was 1 to 82 days (mean = 12.8 days).
Fourteen (34%) of these patients had an admission diagnosis of respiratory problems, followed by coronary disease
(16%), infections (12%), falls (12%) and cancers (10%).
Of the 51 patients successfully recruited to the trial, one patient developed a sacral pressure injury. Six patients in the
pseudo control group developed a sacral pressure injury. The results indicate that the pseudo control group was 5.4
times more likely to develop a pressure injury than the trial group (p≤ 0.08). The sacral dressing is now used routinely in
the medical units as part of a pressure injury prevention plan.
Conclusion - Applying a protective sacral dressing with a low-shear backing as part of a pressure injury prevention
regime could be beneficial in the prevention of pressure injury in older ‘at risk’ medical patients. Further research is
required to determine the efficacy of the prophylactic dressing applications designed to reduce sheer, friction and excess
moisture in other groups of high risk patients.
0430
Association between nonverbal behavior and quality of disclosure of adverse events
Susumu Seki, Mio Sakuma, Kaori Takada, Takeshi Morimoto
Center for Medical Education, Kyoto University Graduate School of Medicine, Kyoto, Japan
Objective:
To assess the nonverbal behavior during disclosure of adverse events, and its associations with quality of disclosure.
Methods:
We developed disclosure training of adverse events with simulated patients. 2nd year medical students were presented
the hypothetical scenarios of adverse events with errors, and asked to be a healthcare professional in charge. They have
to explain the incidents to the simulated patients (SP) in 5 minutes. The disclosure was conducted twice for different
scenario and simulated patients. We recorded disclosure explanation trainings on video by 3 cameras. A camera captured
whole scene, and the other two cameras were taken for each SP and student. We observed for one student each these 3
videos simultaneously, and annotated the utterance and the face motion by annotation software ELAN. Using these
annotation results, we calculated 3 features, the total duration of utterance, the total duration of watching SP's face, and
the total duration of nodding. These features are basic nonverbal features in discourse analysis. The major role of
utterance is sending information, the role of watching face is detecting information, and the role of nodding is control of
information flow. We conducted Spearman correlation analyses the questionnaires asking the following domains: fullness
of explanation; satisfaction of family; express of apology; sincerity; and disclosure about error, if any. Simulated patients
were also asked about their intention to continue the care and to sue the doctor. Students were also asked about
necessity of apology, and feeling bewildered. These domains were rated by 5-scale. 10-scale global quality of explanation
was graded by both students and simulated patients.
Results:
4 medical students enrolled in this study. The utterance correlated with SP's sincerity (rho=0.73), the watching SP's face
correlated with feeling bewildered (0.76), the nodding correlated with students' disclosure about error (0.87) (Table1).
Conclusion:
Assessments of nonverbal behavior were associated with quality of disclosure. Such behavioral features might reflect the
hidden anxiety. Our proposed assessment of nonverbal behavior could be used in other setting, such as practicing
physicians.
Table 1. Correlations
0433
Integrated approach to patient relation management using e-Feedback System
1
1
1
2
May-Chin Yong , Ai-Sim Tan , Thomas Chee , Jemin Chua
1
2
Tan Tock Seng Hospital, Singapore, Nanyangl Technological University, Singapore
Objective:
This paper sets out to describe how a tertiary hospital uses a web-based system to integrate the process of managing
feedback, governance and related learning/research activities.
Introduction:
The current system in this tertiary hospital involves the Patients Relations Unit being a central body to document
communications related to patient’s complaint. This information is stored in multiple files and in several locations making it
not easily retrievable for management report, staff learning and research. To meet the needs of multiple stakeholders,
there is a clear need to have a single system to allow staff to access information on-demand and to be able to have
reports readily available for management purposes.
The Initiative:
To develop the system, feedback from staff gathered throughout end 2008 to mid 2009 was used to establish user and
system requirements. Subsequently, a thorough vendor evaluation was carried out to ensure critical criteria were met
before development of the system. In early 2010 a multidisciplinary team of staff was invited to view a mock- up of the
system and to participate in the Failure Mode Effect Analysis (FMEA) to preempt problems that may arise when the
system goes live. This is followed by a user acceptance testing, further fine tuning and end-user training. The e-Feedback
system is expected to go live on the end of February, 2011.
Fig 1. Timeline of events.
Features of the system:
A proactive workflow is incorporated into the system, by which when a new case is submitted, an auto-notification
message will be sent to the relevant heads of departments. The reminder function may also be used to instruct the
system to send automated reminders to relevant parties who have yet to provide their inputs after a designated time. The
search function allows users to search for past correspondence with the patient/feedback provider, which helps to
maintain a level of consistency when replying to their feedback. Letter templates reduce the need to navigate out of the
system to generate the reply letter.
Aside from providing case inputs, users of the e-Feedback system can also view inputs from other stakeholders involved
in the case as this system also serve as a common communication platform. In addition, with the customized dashboard
view, head of departments and senior management are able to view all current and past cases, as well as the number of
feedback that each department received. In knowing so, the hospital can direct its resources to more pertinent care areas.
Although the system will be used primarily for the day-to-day management of patients’ feedback, it also functions as an
integrated multi-purpose system that can facilitate learning through the use of graphic, video and audio files, and also as a
knowledge database for hospital research projects.
Conclusion:
This integrated system enables for a more consolidated and convergent management of cases and relevant data. In
addition, a significant push towards this development and adoption of an electronic system is also in response to the
increasing patient expectations for a swift response, thorough investigation of feedback, and transparency of the
complaints procedure [1].
One major limitation of this system is that despite the correspondence between patient relations staff and the parties
involved being electronic, case notes of patients however, are only provided in hard copy and transported manually, which
departs from the virtual, no-hassle approach which the e-feedback system adopts.
Reference:
1.
Friele RD, Sluijs EM, Legemaate J. Complaints handling in hospitals: an empirical study of discrepancies
between patients’ expectations and their experiences. BMC. 2008;8:199.
0434
National Clinical Quality Registries
Niall Johnson, Elizabeth Hanley, Margaret Banks
Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia
Objective:
The development, testing and validation of Operating Principles for Australian Clinical Quality Registries to enhance the
value and utility of registries.
Methods:
In 2007, the Australian Commission on Safety and Quality in Health Care identified the potential (and current limitations)
of registries for providing high-quality, clinically relevant information on the safety and quality of care, including
medications, devices and treatments. In collaboration with the Centre for Research Excellence in Patient Safety, Monash
University (CREPS) and the National E-Health Transition Authority (NEHTA), the Commission developed draft national
Operating Principles and Technical Standards for Clinical Quality Registries.
In 2008, the Commission contracted six registry groups to report on the applicability and feasibility of the draft national
Operating Principles and Technical Standards for Clinical Quality Registries, and to recommend any amendments
resulting from the testing and validation program. The contracted registry groups were:
•
Australasian Rehabilitation Outcomes Centre (AROC)
•
Australian Cardiac Procedures Registry (ACPR)
•
Australian Stroke Clinical Registry (AuSCR)
•
Bi-national Burns Registry
•
National Breast Cancer Audit (NBCA)
•
Neck of Femur Fracture Registry of Australia (NOffRA)
The draft Operating Principles were tested and validated in six clinical quality registries with an external evaluation
conducted concurrently.
Results:
The reports of the six testing projects and the independent external evaluation team were all strongly positive, while
offering advice for further refinements. The revised Operating Principles represent a comprehensive and objective set of
evaluation criteria for Australian Clinical Quality Registries.
The refined Operating Principles, and the accompanying set of strategic principles, were endorsed by Australian Health
Ministers in November 2010.
Conclusions:
Clinical quality registries can enhance national reporting for quality improvement in a way that is patient-centric, efficient,
and quality-focused. They can enable clinicians, consumers, governments and other stakeholders to monitor and report
efficiently on the appropriateness and effectiveness of care at hospital level, within a framework that supports better
understanding of variation, quality improvement and research.
The final 41 Operating Principles for Australian Clinical Quality Registries provide guidance for those considering,
operating and/or funding registries.
This presentation will cover the value and uses of clinical quality registries and how the Operating Principles aid in
delivering high-quality information on the safety and quality of care.
0436
Enhancing Quality and Safety Care for Patients with Invasive Mechanical Ventilation (IMV) in Hospital
Chung Leung Henry Poon, Yuet Kwai Chan, Pui Yee Ho, Shu Wah Ng
United Christian Hospital, Hong Kong
Introduction
Invasive mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. It is a life-saving
intervention; however, it may lead to certain potential complications including pneumothorax, airway injury, alveolar
damage, and ventilator-associated pneumonia. Therefore, it is important to have a mechanism in place to ensure save
and effective operation of and caring patients on invasive ventilator. As a self-initiative, promotion programs have been
implemented since 2008 to enhance the safety and quality of care for patients on IMV.
Objectives
1)Enhance quality of care for patients on IMV; 2)Establish a mechanism in place to ensure quality care of it
Methodology
In line with corporate service plan, all invasive ventilator machines were modernized and unified in the Department of
Medicine & Geriatrics since 2008. The updated version of ventilator is Magnetic Resonance Imaging (MRI) compatible
and provides visual and audible alarm to signal that some problems are occurring to ensure safety of the patient. Our
practice on care of patient on IMV was reviewed against the updated guideline. There are few areas identified for
improvement as below.
Guideline
The guideline were revised and updated with reference to corporate guideline (Nursing Standard for Respiratory Care; No
12. Care of Patient with Endotracheal Tube) and best available evidence e.g. from BTS. The aim of this guideline is to
provide recommended standard practices with reference to corporate guideline and best available evidence on caring
patients with invasive ventilation support.
Competence enhancement
There are two lessons conducted since 2010 with one to two hour practicum with direct coaching has been provided for
more than 70 colleagues in M&G department. Re-demonstration or quiz is required for candidates to test their
competence.
Quality assurance
A practical guideline for the updated version of ventilator established and accessible in all the units of Medicine &
Geriatrics. We have phone and out-reach consultation services provided for prompt and continuous quality assurance.
Video demonstration of setting and operation of the IMV machine is accessible in hospital webpage.
Logistic management and patient registration
All IMV machine are centralized in a designated ward for storage, maintenance and distribution in order to maintain a safe
and effective utilization. Further, all patients on IMV would be registered in a respiratory ward to facilitate communication
and comprehensive management.
Results
Quality care for patients on IMV has been promoted in the hospital. A mechanism is in place to ensure the safe and
effective care. Nearly all (97%) candidates are satisfied with the training programs and the colleagues’ knowledge was
significantly improved after attending the course (p-value < 0.001).
Conclusion
The promotion provides a mechanism in place for quality assurance for caring patients on IMV. Competence of
colleagues to care patients on IMV has been improved. More services outcomes remain to be explored such as
compliance rate, complication prevention and hospital length of stay.
0437
Satellite Pharmacy Room – An effective way to manage medication inventory in wards
1
1
2
3
LAW Kwok-man , SUNG Wing-kuen , MA Kit-ching , CHIN Wai-hung
1
2
Castle Peak Hospital, Hospital Authority, Hong Kong, China, Pok Oi Hospital, Hospital Authority, Hong Kong, China,
Tuen Mun Hospital, Hospital Authority, Hong Kong, China
3
Objectives
To improve management of ward medication inventory, and reduce wastage of manpower.
Methods
Castle Peak Hospital is the psychiatric hospital with longest history in Hong Kong. The total number of wards is 24 with
more than 1000 beds. The ward medication inventory in wards has given rise to the issues of excessive storage,
involvement of intensive manpower for maintenance, and occurrence of medication incident. A Lean Management Team
was established in November 2009 to sort out these problems by using the method of Plan, Do, Check, Act (PDCA).
Plan:
- Meeting with ward and pharmacy staff, onsite visits to explore work flow of medication management
- Root cause analysis
- Construction of current and future Value Stream Mappings
Do:
- To establish a Satellite Pharmacy Room in 6 pilot wards. The room was accessible by ward staff 24-hour a day, 7-day a
week and managed by pharmacy, including topping up of the medication inventory, checking of expire date, stock-taking
and recording
- An innovative medication management system was specifically designed for the management of medication retrieval
and stock level. The interface of this computer system was simple and user-friendly. The process of identification and
retrieval of the medication was newly designed. Error proofing function was also integrated into this system. Notification
and electronic reports, weekly and monthly, would be automatically generated and sent to responsible persons.
- 5S, visual management, and rule of first-come-first-out were adopted to facilitate the work flow and stock management
Check:
- The self-reporting information in terms of frequency and time on utilisation of the satellite pharmacy room was collected
from wards. The actual consumption of medications during pilot phase was counted.
- Feedback was collected from frontline ward staff. Further improvement works were conducted based on staff’s opinion.
Act:
- The improvement in management of ward medication inventory was confirmed and the satellite pharmacy rooms would
be established for remaining wards.
Results
Outcome measures
Medication Cabinets
Satellite Pharmacy Room
Change (%)
1. Quantity of medication inventory storage
$56,740.2
$32,679.5
-42.4
2. Manpower of ward staff (in 3 months)
72.8 hrs
23.9 hrs
-67.0
3. Manpower of pharmacy staff (in 3 months)
19.5 hrs
14.1 hrs
-27.0
Conclusions
The setting up of Satellite Pharmacy Rooms is highly accepted by different involved parties, from the administrative level
to pharmacist and ward nursing staff. The reduction of ward medication inventory and manpower for medication
management are significant. Health care services are complex processes. Variations and non-value added activities are
inherent to these processes. This project is a good demonstration that by applying Lean principles, we could help hospital
increase efficiency, streamline processes, reduce costs, and provide high quality care to the patient.
0438
The Roles of Operating Room Nurses on the Electronic Nursing Records – An Example of the Radio Frequency
Identification System
1
2
1
Hsueh-Ling Ku , Jun-Der Leu , Pa-Chun Wang
1
2
Cathay General Hospital, Taipei, Taiwan, National Central University, Taoyuan, Taiwan
Objective:
Based on the concept of the patient-centered care, the purpose of this study is to establish a specific system of electronic
nursing records for surgery patients by incorporating an RFID system into the medical process. Through this system, OR
nurses can use a computer to automatically track and monitor the entire operation process of surgery patients.
Methods:
As surgery patients entered the hospital, they were asked to put on an active RFID tag with a bar code, which was
connected to an ultra-mobile personal computer (UMPC) and a computer, where OR nurses could key in patients’
operation details. The data input in this system included the prognosis, condition, and operation details of a patient,
starting from patient registration and including pre-anesthesia consultation, pre-anesthesia preparation, OR entrance,
anesthesia works, pre-operation preparation, operation, operation processing, operation completion, and anesthesia
termination, and transferring. The OR nurses and staff in the Quality Control Center and Information Department worked
collaboratively to implement and test the RFID system, establish the electronic nursing records system, and perform
nursing staff training. Then, the nurses provided an evaluation of this system.
Results:
st
OR nurses’ on-line utilization of this system and the evaluation: This study includes 7,200 patients entered from March 1 ,
st
2008 to December 31 , 2009, suggesting an average of 350 patients per month. One hundred percent of cases met the
correctness of surgery requirement, and no near-miss malpractice occurred. Implementing this system reduced the
human resources needed to key in surgery information. In addition, the system could instantly display the operation
condition, enhance OR utilization, improve management and utilization of medical supplies and appliances, assure the
correctness and immediateness of surgical information, avoid human errors, and relieve the anxiety of the patients’
families by providing prompt information about the surgery. Users completed an evaluation of this system in August 2009.
The results showed that 88.3% of users thought the system was easy to use, 92.6% of users agreed that the system
could enhance the communication in the operation team, and 91.3% of users agreed that the system improved patient
identification and surgical safety. The results for convenience of the computer device, easiness of data entering,
convenience of data entering, timely effect of the data, and the easiness of data print-out all reached an acceptable level
(an average of 85 points or above).
Conclusions:
Providing nursing care in ORs is highly challenging and the OR is a dynamic and changing medical environment. Surgery
patients rely heavily on the proficiency of nurses. Immediateness and continuity characterize the nursing care given
during the surgery period. With the application of the RFID system, nurses, through training, developed appropriate
communication skills and manners on medical records writing and fulfilled the goal of constructing a “complete and
comprehensive medical record” for patients. In this study, we comprehensively and accurately completed the electronic
medical records for surgery patients. Furthermore, we served as a proper communication channel by instantly providing
this information for healthcare staff.
0441
The Quality of Care in Adult Patients with Community-Acquired Pneumonia in a Regional Teaching Hospital
I-Nan Lin, Kou-chou Hsieh, Huan-Sheng Chen, Yu-Chang Li
Landseed Hospital, TaoYuan, Taiwan
Objective:
To improve the quality of care in adult patients with community-acquired pneumonia in a regional teaching hospital
Method:
1. We established the community-acquired pneumonia guideline in our hospital and monitored the adherence of
guideline in daily practice, including proper antibiotic choices either at emergency room or after admission, the
execution rate of sputum culture, the execution rate of chest X-ray follow-up after admission.
2. The measures described below were performed from 2010 August to 2010 December.
（1）We gave every clinician the handbook of guideline. Then we introduced the guideline in the morning meeting of
internal medicine department and the meeting of emergency department.
（2）We made an order list according to the guideline in our electronic medical record system, thus our stuff could make
correct medical order quickly.
（3）Peer review of medical records was performed by attending physicians with a check list according to guideline.
Anyone who didn’t follow the guideline would be informed by telephone or email.
Result:
1. During the period of survey, the average time of initiation of antibiotic treatment after patient’s arrival (in emergency
department) is less then 4 hours.
2. The accurate rate of initial antibiotic use increased to 86% as compared with 82% in 2009/08-2009/10.
3. The accurate rate of antibiotic use after admission increased to 98% as compared with 94% in 2009/08-2009/10.
4. The execution rate of sputum culture increased to 93% as compared with 81% in 2009/08-2009/10.
5. The execution rate of chest X-ray follow up after admission increased to 97% as compared with 71% in 2009/082009/10.
6. The overall mortality rate decreased to 8.4% as compared with 10.6% in 2009/08-2009/10.
Conclusion:
Pneumonia is the 4th leading cause of mortality in Taiwan. With the use of guideline, order list in electronic medical record
system and peer review of medical records, we improved the quality of care in adult patients with communityacquired pneumonia and therefore decreased the mortality rate. In the future, we hope that the electronic medical
record system could play more roles on reminding and quality control.
0442
Moving Patients? Impact of Nursing Unit Transfers and Room Changes on Patient Safety Outcomes
Lindsey Haas, Paula Santrach, Stephanie Bagniewski, James Naessens
Mayo Clinic, Rochester, MN, USA
Objective:
We sought to identify whether or not transferring patients from room-to-room or between nursing units within the hospital
poses additional risk of an adverse event.
Methods:
The retrospective study was conducted within the hospitals at a large, Midwest US academic center among medical
inpatients 1 years of age or older admitted from January 2008 to December 2008. Transfers were identified from the
hospital admit, discharge, transfer system and classified into a hierarchy of 1) level of care changes (e.g., general floor to
intensive or special care), 2) other nursing unit changes, and 3) room changes within the nursing unit. Analyses were
conducted to examine the possible relationships between transferring a patient and subsequent identification of an
adverse event with harm. Adverse events were obtained from provider event reporting system and included events such
as equipment, falls, medication errors, miscellaneous and skin impairments. Harm was defined as level E or higher on the
National Coordinating Council for Medication Error Reporting and Prevention. The effect of a physical transfer on patients’
outcome was assessed using a logistic regression model incorporating adjustments for age, gender and acute physiology
score at time of admission. Separate analyses included any transfer, and then also considered the level of transfer. When
analyzing the level of transfer only the first move was analyzed as follows: first level of care changes were compared to all
other patients; next unit changes were compared to all remaining patients; finally, room changes were compared to all
nontransferred patients.
.
Results:
There were 24,797 medical patients. 26.4% (n=6,547) of discharges had at least one physical transfer during their stay
(54.8% n=3588 Level of Care transfer (2.2% AE); 17.5% n=1148 Unit Transfer (1.0% AE), 24.7% n=1811 room transfer
(1.4% AE) . Adverse events were directly related to transfers (p-value <0.0001) with 1.8% of the transfer population
having had an adverse event compared to 0.8% of the nontransfer population having had an adverse event. In our
logistic regression model, adjusting for severity and other predictors, the risk of an adverse event causing major harm was
nearly five times as likely among transferred patients (odds ratio, 4.81; 95% CI 2.70 - 8.56). Turning to our second
analysis, comparing level of care changes to all other patients, we see similar results; transfers were nearly two times as
likely to have an adverse event(OR 1.9, 95%CI 1.42 - 2.55). Most interesting, individuals transferred between rooms in
the same nursing unit appear to be associated with higher rates of adverse events with harm and major harm. (AE = OR
1.83 p-value 0.006, AE Major Harm = OR 3.24 p-value 0.013)
Conclusions:
One of the root causes of many adverse events has been shown to be problems in handoff communications. Our results
indicated that transferring patients appears to increase the risk of an adverse event occurrence. Even transferring a
patient between rooms on the same floor was associated with higher rates of adverse events with harm. Patient transfers
should not be made without clinical justification. Patient management and monitoring should increase following a transfer.
Optimal health and wellness of the patient should be the principal goal of any physical transfer; we speculate that
reducing the number of unneeded moves could potentially reduce the patient’s risk of an adverse event.
0443
Fostering Information Security Culture in Kowloon East Cluster Hospitals
Cheng Ka Pui, Gladys
United Christian Hospital, Hong Kong
Objective:
To foster and instill information security culture in Kowloon East Cluster (KEC) hospitals so as to safeguard personal
information.
Methods:
The need for organizations to address the issues of information security is undeniable. To raise everyone’s level of
security awareness, KEC Information Security Privacy (ISP) office has organized a series of projects and CQI initiatives to
engage staff and subsequently hope to foster information security culture in KEC. KEC ISP Team was set up. By
adopting the Focus, Analysis, Develop and Execute (FADE) cycle approach, the team identified the problem, international
trends and strategies through the following phrases:
Focus:
Data collection from international privacy incidents, Hospital Authority Advanced Incidents Reporting System
(AIRS) and nearly missed cases for identification of improvement areas.
Analyze:
By the use of Fish-bone diagram to analyze Man, Machine, Material, and Method for solutions developing.
Develop: Solutions
1. Security awareness training and seminar:
 Reinforce both the letter and spirit of law and Data Protection Principles to staff through orientation program and
seminars.
2. Education and promulgation
 Created KEC ISP webpage which features the latest news of ISP, as well as a comprehensive list of training and
educational materials.
 KEC ISP Policy Statement: it was signed by our Cluster Chief Executive so as to show top commitment on
Information Security and posted in every working place in KEC.
 Recruited ISP ambassadors: We aim at setting up a mechanism for maintaining contact with ISP Ambassadors from
various departments, disseminating and conveying ISP message in their respective department and helping to abate
ISP hazards.
 Designed 4 sets of ISP poster and Q card which posted in every working place. It aimed at reminding staff on some
important concept of information security.
 Disseminated ISP Alert: International privacy incidents and alert were disseminated through newsletter and email to
increase staff alertness on information security.
Execute: Periodic evaluation and testing of the effectiveness of security policies by senior executive walk round and
audit. The frequency is not less than annually. Remedial action to address any deficiencies found to be properly managed.
Results:
Staffs are adhered to data protection principles which can be reflected by the satisfactory result on annual ISP compliance
audit.
Conclusions:
Individual ISP project not only delivers small improvements but it did also achieve the objectives of fostering information
security in KEC.
0445
Building staff-patient partnership through engaging staff to listen to patients’ voice
1
2
3
3
Kah Lin Choo , Cecilia Kwan , Janice Wang , Hong Fung
1
2
3
North District Hospital, Hong Kong, Bradbury Hospice, Hong Kong, New Territories East Cluster, , Hong Kong
Objectives:
1. To assess healthcare workers’ response to constructive patient feedback on web-based video interviews
2. To encourage healthcare professionals to reflect upon their interactions with patients and relatives
Methods:
Patients and relatives who were willing to undergo video-recorded interviews recounting both their positive and negative
healthcare experiences were invited to participate in this study. Each video together with a short survey was then posted
on the website of New Territories East Cluster (NTEC) that is accessible by more than 9000 NTEC staff. The video was
edited to a length of three minutes and the survey consisted of three questions eliciting a yes/no answer. Each question
explored staff’s attitude towards universal values, their opinion on patients’/relatives’ feedback and encouraged them to
relate the scenario to their own work experiences. The project was introduced at a Caring Forum in October 2009 and the
February 2010 video was screened at a forum hosted by Cluster Chief Executive with open discussions on survey
questions. The individual video hit rates and online survey participation rates were monitored from October 2009 to May
2010.
Results:
Five relatives and two patients participated in the production of four video interviews with themes ranging from intensive
care, surgery, medicine to oncology. The videos were launched between October 2009 and February 2010 on NTEC
website. As in May 2010, the hit rate for the four videos reached 2726, 2066, 1074 and 1373 respectively. The online
survey with an intensive care theme attracted a response of 452, the surgery theme 457 responses, the medical theme
351 response while the oncology survey yielded 629 responses.
Majority of staff upheld universal values such as compassion and communication as evidenced by positive responses
submitted by 91% and 97% respectively. Most agreed that patients should be given a choice in selecting their preferred
treatment (80%) and adequate time should be provided for patients to think through the options before committing to final
decisions (86%). Most staff considered patients/relatives as their partners (85%) while 62% disagreed that
patients/relatives were over-demanding. Seventy-nine percent of the staff claimed they would perform detailed
assessment of patient’s abilities as opposed to on-the-spot judgment while 72% felt they could individualise patient care
during their daily routines. Spirit of teamwork at their workplace was acknowledged by 69% while 59% would take the time
to listen to patients with unclear speech. Sixty percent of the staff felt that heavy workload had led to desensitisation of
their feelings and erosion in compassion.
Conclusions:
The use of an online survey to web-based video was an innovative approach to explore staff responses to patients’
constructive feedback. In general, staff upheld universal values and respected patients and relatives’ rights and choices.
As responses were submitted anonymously, honest replies were elicited regarding the cause of erosion in compassion
among healthcare workers. The authenticity of the video interviews by patients/relatives recounting real experiences not
only served as a platform for patients’ voice but also aimed to create a powerful impact on staff as they reflect upon their
own work experiences. It is hoped that the videos and survey questions would inspire healthcare workers to close the gap
between their aspirations and actual work practices.
0451
The improvement of work effectiveness through the enhanced discharge review process
Chang-sook Jang
SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL, BUNDANG-GU,SEONGNAM-SI,GYEONGGI-DO, Republic of
Korea
Objective
Case management can be defined by such tasks as estimating reasonable medical expenses, providing information for
medical teams, patients and guardians, counseling patients on medical expense, and monitoring and assessing medical
expenses.
Patients and caregivers wish to return home by paying their medical bill as soon as possible if discharge is determined
after treated in a hospital, however, in the course of case management, it was found that there arise some factors which
delay and disrupt discharge procedure, that is, confirmation process for medical fee, for example, medication, charges for
an operation, nursing care, diagnostic test etc. therefore is focused on improving such problems.
In the analysis of the patients who left hospitals from Oct. to Dec. in 2009, the completion rate of discharge screening was
37.4% at 10 a.m. and 90% at 2 p.m., accordingly the objective of this activity is to raise the rate to 60% by 10 a.m. by
setting the completion rate of discharge screening as a key index.
Methods
In order that only the medical expense for the day can be evaluated on the day when a patient leaves hospital as medical
expense was determined before discharge order, the approaches to address the aforementioned problems are as follows;
1) In regard to computer-related issues, the development and change of program in consultation with the Information
System Team
2) Improving the problems of inefficient financing screening
3) Improving complicated change process
4) Improving the method to process medication return
Results
The completion rate of discharge screening before 10 a.m. increased from 37.7% before the correction (Oct.-Dec.2009) to
50.19% after the correction (Aug-Oct 2010) and Sigma level increased from -1.89 to 0.11 sigma, that is 2 sigma level was
improved.
Conclusion
Speedy discharge and evaluation of reasonable medical expense led to the enhanced credibility of a hospital, and from
the decrease of discharge-related call and prompt discharge, the adjustment of sickbed went on smoothly and direct
nursing time was increased.
Financing screening performed on a daily basis resulted in the quality improvement of discharge evaluation, what was
approved on paper when changing pay/extra pay, amount was processed in a screen for them, and the efficiency of case
management tasks improved due to the development of data processing.
0452
Towards the research and development of an automatic cancer notifications system
1
2
1
2
Anthony Nguyen , Julie Moore , David Hansen , Shoni Colquist
1
2
Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia, Queensland Cancer Control Analysis
Team, Queensland Health, Brisbane, Queensland, Australia
Objective:
To develop an innovative system for the automatic classification of cancer notifications data from free-text pathology
reports.
Methods:
The system automatically scans HL7 messages (containing free-text histology and cytology reports, including associated
metadata) from the Queensland Oncology Repository (QOR). It looks for cancer characteristics such as primary site and
laterality, histological type and grade, date and basis of diagnosis, cancer stage, and other synoptic data that is relevant
to the notification of cancers. Non-notifiable cancers such as non-malignant cancers, and squamous cell carcinoma (SCC)
and basal cell carcinoma’s (BCC) of the skin were also identified, but removed and flagged by the system.
The proposed system builds upon the Medical Text Extraction (MEDTEX) system [1], which comprises of the identification
of medical (or more specially SNOMED CT) concepts in the free text, and the detection and application of medical
negation phrases to relevant disease and finding concepts. Additional analysis engines include further pre-processing to
segment the free text into sections, and the extraction of items relevant for cancer notifications. The underlying technology
used for the extraction of cancer notification items is based on the symbolic rule-based classification methodology
presented in [2]. Business rules for cancer notifications according to the clinical coding manual used by cancer registry
coding staff [3] was also incorporated with the aim to mimic the processes adopted by the cancer registry.
Results:
A baseline system was developed on a corpus of 239 histology and cytology reports. The gold standard used for system
evaluation was based on an error analysis between the reference data set provided by a clinical coder and the output of
the system. Only the following cancer notification items were evaluated: primary site (287 classes represented by an ICDO topology code), laterality (5 classes), histological type (5 digit number; first 4 digits ranging from 8000 to 9989, and the
last digit can be 0-3, 6 or 9), histological grade (9 classes), and basis of diagnosis (4 classes).
The overall accuracy of the current system was 88%. No reports were available in the data set for testing the basis of
diagnosis of “autopsy and histology”. The accuracy within each notification data element was 96% for basis of diagnosis,
87% for histological type, 95% for histological grade, 75% for primary site, and 85% for laterality.
Conclusions:
The cancer notifications system is currently under development and preliminary results show promise. Additional data will
be used to iteratively develop and test the system. Cancer registries collect a multitude of data which requires manual
review, slowing down the flow of information. By producing the automatically filled forms for review, the reliance on expert
clinical staff can be lessened, thus improving the efficiency and availability of cancer information.
[1] A. N. Nguyen, et al., "A Simple Pipeline Application for Identifying and Negating SNOMED Clinical Terminology in
Free Text," in Health Informatics Conference (HIC), Canberra, Australia, 2009, pp. 188-193.
[2] A. N. Nguyen, et al., "Symbolic rule-based classification of lung cancer stages from free-text pathology reports,"
Journal of the American Medical Informatics Association, vol. 17:, pp. 440-445, July 1, 2010; 2010.
[3] Queensland Cancer Registry, "Clinical Coding Manual Version 3."
0458
Discussion on the needs of the families of dying patients.
Mei Ling Fang
Far Eastern Memorial Hospital, New Taipei city/Head Nurse, Taiwan
Objective:
Despite the social composition is changing rapidly, family members are still the major care providers for patients in
Taiwan. When the patients are facing their upcoming deaths, it is also the beginning of family members’ sorrow and grief.
For healthcare workers, except for caring the dying patients, we should pay attention to the family members about their
feelings and needs, to accomplish a holistic care. Although there are plenty of studies about the attitudes of patients
facing the deaths, there is limited information about the need of family members of dying patients. We hope this study can
provide insights about the strategy of caring family members of dying patients, and be part of educational training of
nurses.
Methods:
The goal of this study is to evaluate the needs of family members of dying patients. The study is a descriptive-relational
design . We select family members of dying patients in medical, surgical and intensive units in a medical center in New
Taipei City. A structural form is used, including the demographic information of family member and patients, and the
needs of family members, which contains factors related to clinical condition of patients, medical cares, social supports,
and environments. The Cronbach’s Alpha value between factors is 0.97. The study period is from December 2008 to June
2010, planed to enrols 100 family members. When there was a suitable case, the study team will be introduced to the
case by the chief nurse of the unit. Informed consent will be obtained before enrolment, and the case has the right to
decline the study at any time. All the data is collected anonymously, and all the data will de coded, and analysis with
spss10.0 for windows software.
Results:
Results showed the 64 family caregivers were enrolled in our study after getting written informed consents between
December 2008 to June 2010.Using factor analysis method, there are 5 main factors including needs.The mean time of
interview for caregivers is 24 hours after the patients’ admission.Descriptive statistic indicated that caregivers had a high
needs.The most important is” information needs” followed by “self needs”, “take care of the patient's needs”,
”processing demands death needs” and” spiritual needs.”
Conclusions:
According to the findings mentions above, clinicians are urged to assess regular the degree of family caregivers needs.
Study results suggest providing respite care to family caregivers as appropriate. The authors recommend conducting a
prospective study to test the effectiveness of intervention in reducing caregivers needs satisfaction.
0459
‘The Boarding Pass’ to Safer Imaging
Doreen Pawley, Matthew Chu
Canterbury Hospital Sydney Local Health Network, Campsie NSW, Australia
Objective
To implement an effective strategy to mitigate the human error risks in the radiological test journey.
Background
Following the introduction of electronic radiological test ordering within the Emergency Department of a Metropolitan
Hospital , a number of incidents relating to errors in the pre-procedural and procedural phases of the imaging cycle
occurred. Errors were multidisciplinary in nature and involved test requisition, patient transport and test performance.
Electronic test ordering did not have the capacity for a failsafe selection of the correct patient details and errors made in
this area were unable to be detected by other workers involved in the imaging journey. Patients were not provided with a
hard copy document to be able to detect the errors themselves. The electronic requests was only printed out in the
radiology department and not available to the requesting clinician. Despite the introduction of various strategies following
root cause analyses to remedy an identified single problem, other problems arose. In total, seven incidents occurred over
an 18 month period. These were given the highest risk rating of the Severity Assessment Code 1 (SAC1) under the New
1
South Wales(NSW) Health Patient Safety Program. In 2007 , 70% of reportable wrong patient/site/procedure incidents
occurred in imaging/nuclear medicine despite a mandated “time out” policy in place for several years in NSW. The policy
failed to adequately address all the human error risk factors in the imaging journey.
Methods
A team involving the Emergency Department, Radiology and Quality Unit undertook a modified fail mode event analysis /
process mapping. The human factor weak links were identified. Risk reduction measures were undertaken to address
these weaknesses.
Results
A complementary paper based system consisting of a series of checklists which travelled with the patient was introduced.
This was coined the “boarding pass”, adopted from the final passenger identification check utilised in the airline industry.
The electronic radiological request was regarded as the “e-ticket” and the hard copy “boarding pass” was needed to
match the e-ticket before the test was undertaken. In the event of a mismatch of the “boarding pass” to the “e-ticket,” the
patient does not proceed to the next stage of the process unless the mismatch is rectified. The boarding pass
incorporates the Emergency Department “check out” and the Radiology mandated “time out”.
No SAC1 incidents have occurred in the past 3 years since the introduction of the “ED boarding pass” despite an 18%
increased demand for radiological testing. Thus saving time and money and patients to unnecessary exposure to Xray.
Conclusion
The introduction of the “boarding pass” is a successful low cost strategy in the prevention of ”wrong patient- wrong sitewrong procedure” errors in Emergency Department initiated electronic radiological investigations. The boarding pass
manages the human error risks more adequately than the previously “time out” procedure. The Boarding pass was not
introduced into the inpatient ward where SAC 1 incidents have continued to occur. The unexpected benefits include
improved compliance relating to patient identification through wrist banding and the standardisation of instructions for
radiology test preparation, patient involvement as they had a boarding pass in their hand, which assisted new or
inexperienced staff. Thus ensuring standardised and efficient radiographic preparation. This initiative may be
implemented in other clinical settings (with or without electronic requesting) where correct patient identification and
standard operating procedures are paramount in the patient journey.
1
NSW Health & Clinical Excellent Commission- “Incident Management in the NSW Public Health System 2007” pp30
0461
FIVE MOMENTS THAT MAKE A DIFFERENCE: OUTCOMES FROM THE AUSTRALIAN HAND HYGIENE INITIATIVE
Marilyn Cruickshank, Margaret Duguid, Elizabeth Hanley
Australian Commission on safety and Quality in Health Care, NSW, Australia
Introduction: Patients rightly expect to receive safe, high quality health care. The healthcare system generally fulfils this
expectation and provides excellent care. However, some patients acquire infections which are a leading cause of
preventable, and sometimes serious, harm. Apart from the pain and suffering caused to patients, healthcare associated
infections also have significant resource costs, prolonging hospital stays, requiring medications, procedures and testing creating more work for health care staff. Each year in Australia there are about 200,000 healthcare associated infections.
Prevention of infections is the responsibility of all who care for patients, and costs less than treating such infections.
Hand hygiene compliance by health care staff is regarded as the single most effective strategy in the prevention of
healthcare associated infections.
The National Hand Hygiene Initiative was endorsed by all Australian health ministers and implemented in January 2009 to
standardise hand hygiene through a culture-change program, including the increased use of alcohol-based hand rub,
throughout all Australian hospitals. This national program encourages health care staff to view infections as a potentially
preventable ‘adverse event’.
The National Hand Hygiene Initiative is the only national hand hygiene program that:
◊
uses a standardised measurement tool that facilitates data comparison across hospitals, states and territories.
◊
incorporates data from both public and private sector hospitals.
◊
has both process measures (hand hygiene compliance rates) and outcome measures (Staphylococcus aureus
bacteraemia rates).
Methods: A multi-modal culture-change program based on the World Health Organisation “5 Moments” program was
implemented in all states/territories. It included development of Australian hand hygiene guidelines, state-based
healthcare worker training programs and data collection and analysis tools. Training to standardise hand hygiene
compliance auditing (>90% internal/external validity) was conducted nationally and a four monthly (3 times/year) data
submission schedule established. Electronic and on-line data submission capability have enhanced efficiency and
participation. Outcomes 24 months after National Hand Hygiene Initiative commencement were assessed.
Results: After 24 months, 521 healthcare facilities from all states/territories submitted hand hygiene compliance data,
representing approximately 85% and 50% of acute public and private hospital beds respectively. Audits have been
completed for six periods in 2009 and 2010. Over 120,000 healthcare workers have undergone the national training
program, with many hospitals making completion of the hand hygiene program mandatory for all new staff.
The overall national hand hygiene compliance rate has risen to 68.3% (95%CI: 68.1-68.5%) in audit six, from 63% in the
first audit. State-based rates from public hospitals have demonstrated a steady increase to range between 60.8% and
72.6% in the last audit in 2010.
National hand hygiene compliance rates by hand hygiene Moment were: M1: 63.1%, M2: 68.4%, M3: 79.1%, M4: 76.0%,
M5: 60.0% - suggesting that education needs to be focused on improvements in hand hygiene prior to patient contact,
especially before performing procedures (M2).
Overall hand hygiene compliance has been measured according to health professional group. The highest rates have
consistently been among nurses and midwives rising from 69.3 in audit two to 73.9% (95% CI: 72.9-73.4) in audit six;
while rates for medical practitioners continued to be lowest rising from 49.3% in audit two to 51.5% (95%CI: 50.9-52.1) in
audit six.
Conclusion: The National Hand Hygiene Initiative has been associated with a rapid national culture-change among
Australian healthcare workers, resulting in significantly improved hand hygiene compliance and a shift to greater use of
alcohol-based hand rub. Analysis of National Hand Hygiene Initiative impact on nosocomial disease rates is underway
and further improvements in hand hygiene compliance can be expected.
0462
Safe Surgery Saves Lives – the implementation in Hong Kong NTE Cluster
Ellen WONG, Danny CHAN, Michael CHEUNG, LP CHEUNG
Hospital Authority, Hong Kong, China
The World Health Organization launched “Safe Surgery Saves Lives” as the Second Global Patient Safety Challenge in
2008. In Hong Kong New Territories East Cluster (NTEC), the Safe Surgery Policy was launched and implemented in
three phases from Operation Theatre, Interventional Suite to bedside procedure.
Objective
The implementation aims at reinforcing surgical safety by improving the checking process and the communication among
team members of various clinical disciplines.
Method
Phase I – Safe Surgery in Operation Theatre
A Policy on Time-Out to ensure Correct Patient and Correct Site Surgery was developed in 2009, and a checklist “123
Surgical Safety 123” was implemented in October 2009. The checklist was adapted from the WHO Safety Checklist and
addressed the critical processes of a surgical patient journey, i.e. Consenting process (including site markings), Sending
the patient, Theatre reception, Sign in (before Anaesthesia), Time-out (Before incision), Sign out (Before leaving theatre)
into one single checklist. To further enhance the effectiveness and efficiency of the Safe Surgery policy and to improve
the communications between all parties involved in surgical procedures, a combined Safe Surgery 123 and Nursing PreOperation Checklist was developed and implemented in August 2010.
Phase II - Interventional Procedure Safety Procedures
In December 2010, the implementation of safe surgery was extended to outside Operating Theatres so as to reinforce
interventional procedures safety in interventional suites, such as Minor Operating Suites, Interventional Procedures
performed in Radiology suite, all gynaecology procedures, Endoscopy Units, venues for performing Electroconvulsive
Therapy, Cardiac Intervention Centre, etc. A Generic Checklist includes checking for patient identity, consent, infection
precaution, drug and other alert history, Time-Out procedure, instrument and gauze/swab counts before and after
procedure, handling of specimens, and nursing procedure was developed. Different specialties add extra items required
for their specialty on top of the Generic Checklist.
Phase III - Safety Policy on Bedside Procedures
st
The policy for bedside procedure was endorsed in January 2011, and to be effective on 1 March 2011. It aims to provide
a checklist for improving patient safety during bedside procedures. The checklist includes similar essential components as
in other safe surgery checklist. It applies but not limited to Chest tapping, drainage and paracentesis, and Insertion of
intravascular catheter with the use of guide wire.
Result
An audit was conducted in main Operation Theatre (OT) in March 2010. The overall compliance rate to the checklist was
98.8%. The feedback from OT staff was good. After the audit, a video clip was made to demonstrate the checking process
in detail. In 2010. the number of Sentinel Events related to Wrong Site Surgery was decreased from 2 in 2009 to 0 in 2010;
the number of Sentinel Event related to Retained Instrument was decreased from 5 in 2009 to 2 in 2010.
Conclusion
With implementation of the safe surgery policy and the adoption of the checklists, and the efforts of all colleagues, we aim
to prevent further occurrences of the related incidents and improve the care to our patients.
0463
Addressing Quality and Safety Issues in Data Reporting: A Statewide Endoscopy Information System for NSW,
Australia
Kate Needham, Hunter Watt, Ellen Rawstron
NSW Agency for Clinical Innovation, Sydney, NSW, Australia
Objective
Due to uncertainty regarding the number, quality and safety of endoscopic procedures in NSW public hospitals, the NSW
Agency for Clinical Innovation’s (ACI) Gastroenterology Network identified the need for the introduction of a statewide
Endoscopy Information System (EIS).
Method
In 2006, the ACI’s Gastroenterology Network identified that there was inadequate data about endoscopy procedures
undertaken and the efficiency, accuracy, safety and effectiveness of these procedures – in NSW public hospitals. This
deficit in data also meant there was no indicator as to whether the system could deliver the demand for colonoscopies
resulting from the National Bowel Cancer Screening Program and report on NSW participation rates.
These issues were examined by the Gastroenterology Network’s Colonoscopy Study Group, whose 2007 study and
subsequent report emphasised that any changes to address deficiencies in endoscopy services in NSW needed to be
underpinned by information systems. The Gastroenterology Network identified that there was need for a statewide
endoscopy data collection and reporting tool to provide timely and accurate data and began advocating for the purchase
of an EIS.
The EIS project was instigated by the ACI Gastroenterology Network, which engaged with clinicians, managers and the
NSW Department of Health to advocate for the purchase of a statewide data reporting system for endoscopy services.
Following identification of an allocation of Commonwealth funds and subsequent provisional NSW Health support for the
EIS, the Gastroenterology Network, in collaboration with NSW Health, established an EIS Executive Group to monitor
progress and provide vital clinical advice on the required EIS specifications. This group included clinical and technical
expertise from across NSW Health and is responsible for providing clinical guidance throughout the implementation of the
EIS from early 2011
In November 2009, a six week system trial was carried out at a major metropolitan hospital. The trial allowed clinicians
from across NSW to evaluate the system and successfully:
 Identified and verified the clinical function of the system;
 Promoted standard work practice;
 Confirmed integration with other hospital systems;
 Confirmed user acceptance by endoscopy staff.
Results
In addition to its role in providing clinician advocacy and expertise, the Gastroenterology Network developed four
minimum data sets, which will form the basis of the EIS mandatory safety and quality reporting fields for statewide
collection.
The successful trial provided the impetus for NSW Health to proceed with the purchase of the EIS. In June 2010, NSW
Health finalised the EIS purchase, which will be implemented at 84 public hospitals over the next two years.
The implementation of a standardised endoscopy reporting system will alter the way in which endoscopy data and
services are managed across NSW, including:
 Provide accurate statewide information on endoscopy carried out in NSW public hospitals;

Facilitate the comparison of services against critical safety and quality benchmarks;

Inform on issues of productivity, activity, costs and access to services for patients;

Support reporting for the National Bowel Cancer Screening Program.

Clinical Research
Conclusions
Clinician engagement and advocacy has been fundamental in realising the acquisition of a statewide EIS. As the
implementation process commences, it is anticipated that clinicians will be instrumental in driving the EIS rollout in their
own hospitals. The EIS will address significant data reporting, quality and safety issues and will allow NSW Health to
better monitor patient experiences and flow within endoscopy services, enabling it to adapt models of care as required.
0465
Using the multimedia to improve the effects of nursing education in patients with open pulmonary tuberculosis
Pei Chia Li, Chin Mei Lai, Yen Chun Chen
Chang Gung Memorial Hospital, Taoyuan, Taiwan
Introduction and Purpose
Pulmonary tuberculosis (TB) is a contagious bacterial infection has been known for centuries that also causes
inflammation and fibrocavitary destruction in the lung, produces chronic respiratory symptoms, and reduces the quality of
life. Tuberculosis is one of the most prevalent infectious diseases all over the world, which causes more deaths than any
other infectious disease. In Taiwan, it was the leading infection disease in 2008. Effective TB treatment is difficult; due to
complex medications usage and at least nine months therapy period. Nursing education is able to improve patients’
knowledge of self-care, to avoid cease treatment.
From January to December in 2009, to the data were collected and discussed in a chest ward. The self-designed
structured checklists regarding sign, symptom, infection process, treatment was established. We found that the
satisfaction average of nursing education of TB only 73.2%. After analysis this issue, we found that the contents and
process of nursing education were incomplete and bored, besides those, it took more than 19 minutes to complete this
nursing education. It also showed that it can’t meet the patients’ needs. It was reflected by the data the cognition of
disease average of TB patients only 66.7%, and the nurses’ integrity of execute the nursing education of TB only have
50.2%.
The aims of this study were to (1) improve the satisfaction of nursing education on TB could up to 85%; (2) the cognition
of disease could increase to 85% in patients with TB; and (3) the completeness of nursing education could be 100%.
Material and Methods
We established two strategies to approach these two issues which were (1) to product a multimedia of TB for improving
patient’s cognition and satisfaction; and (2) to revise the contents and process of nursing education on TB patients for
nurses.
Results
After implemented, the patients' cognition of disease increased to 85.5% and the satisfaction of nursing education of TB
patients up to 85.8%. Besides, the completeness of nursing education increased to 100%.
Conclusion
Using the multimedia teaching strategy is a good way for teaching people simply, lively and impressive. It could be
applied not only for TB patients, but also for patients with other chronic conditions.
0469
Standardized infusion solutions for the risk reduction of pharmaceutical incompatibility
Jinyoung Park, Kyungsook Choi, Eunsook Lee
Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
Objectives:
Parenteral formulations have various pharmaceutical advantages, including a complete bioavailability/maximum efficacy.
However, since this formulation is typically found in aqueous solution, chemical/physical instability may lead to
pharmaceutical incompatibility and, ultimately, to medication errors. Since hospital pharmacists are likely to process
orders compounding parenteral formulation for critically ill patients, standardizations in the preparation and management
may be practically necessary for a safer use of injectable medication. The objective of this study, therefore, was to
prepare standard operation procedures (SOPs) in rectification of pharmaceutical incompatibility.
Methods:
First, we determined the current extent of prescription for injectable medications and prepared/revised the SOPs. Then,
the knowledge-based systems was constructed in our electronic medication record (EMR) system for all of injectable
drugs, including total parenteral nutritions (TPNs), to display warning labels for potentially incompatible prescriptions.
Finally, the management guidelines for high-concentration electrolytes were prepared so that the concentration of the
medication was standardized for risk reduction.
Results:
According to the standardization effort, the SOPs were prepared for virtually all infusion solutions (from 80% to 100%). In
addition, the number of cases for potential incompatibility detected by the EMR system were increased from 3.5 cases to
176 cases per month. Furthermore, the SOPs were prepared for virtually all high-concentration electrolyte formulations
(from 25% to 100%).
Conclusion:
The standardization of infusion solutions is likely to minimize the medication errors and to ultimately lead the improvement
of the quality of patient safety in Seoul National University Bundang Hospital.
0471
Improving clinical management and surveillance of Healthcare Associated Infections through structured
microbiology requests and reports in the eHealth environment
Elizabeth Hanley, Neville Board, Marilyn Cruickshank
Australian Commission on Safety and Quality in Health Care, Sydney, Australia
Objective
This project defines the core information components of structured microbiology requests and reports for Healthcare
Associated Infections (HAI), which are intended for implementation in the eHealth environment to support best practice
clinical management and surveillance of HAI.
Background:
HAI are responsible for a significant burden of iatrogenic morbidity and mortality. Each year in Australia there are about
200,000 HAI.1 Accurate diagnosis ensures that patients receive appropriate treatment and that correct infection control
procedures are put in place.
HAI are diagnosed through microbiology laboratory testing which is currently reported in non-standard formats around
Australia, despite well established use of electronic messaging for transferring pathology results.
Implementation of structured microbiology requests and reports in eHealth will have significant impact on reducing the
rates of HAI because:
• Best practice clinical management of HAI is dependent on the use of best practice pathology requests and reports;
• Effective surveillance of HAI is highly dependent on the microbiology report.
Method:
The Australian Commission on Safety and Quality in Health Care (ACSQHC) led national consultation with peak bodies,
and expert professional groups to develop the clinical information content of microbiology structured requests and reports
for four priority HAI:
• Healthcare associated Staphylococcus aureus bacteraemia (SAB);
• Central line associated blood stream infection (CLABSI);
• Clostridium difficile infection (CDI); and,
• Surgical site infections.
Consultation was undertaken concurrently to identify and harmonise definitions to gain national agreement on surveillance
case definitions for SAB, CLABSI and CDI.
Review of relevant standards, data set specifications and guidelines developed by the National eHealth Transition
Authority, Royal College of Pathologists Australasia, Standards Australia and ACSQHC informed the development of the
core information components. The business process for the pathology Request – Test - Report cycle, and the core
information components were reviewed with a range of health professionals during interviews, at a workshop, and during
site visits, against current microbiology practices. The proposed core information components were then reviewed at a
national workshop and by key stakeholders during a final consultation phase.
Results:
The core information components of structured microbiology requests and reports for HAI have been developed as a best
practice clinical and informatics standard for implementation as part of Australia’s eHealth program.
Representatives of national peak bodies and expert professional groups declared in a national consensus statement that:
• Structured requesting and reporting for microbiology is expected to improve clinical management of Healthcare
Associated Infections (HAI).
• Structured microbiology requesting and reporting is considered a best practice element for clinical management and
surveillance of healthcare associated infection.
• The elements of best practice microbiology requesting and reporting are defined by expert practitioners, and should be
taken up as clinical, laboratory and surveillance standards.
Discussion
Consultation with a wide range of professionals, including pathology providers, microbiologists, infectious diseases
physicians, infection control professionals and e-health informatics experts, was instrumental in gaining support for the
project outcomes. It was recognised that laboratory reporting of microbiology tests using atomic data in structured formats
will improve case management and establish a foundation for efficient, secure electronic surveillance of HAI.
The core information components for HAI are a set of recommended data elements for implementation in any eHealth
environment. However, the implementation of additional clinical requirements in clinical and laboratory information
systems has resource implications for health care professionals, and service providers.
The information requirements for best practice clinical management and surveillance of HAI should be integrated with
other national initiatives in eHealth.
1 Cruickshank M, Ferguson J, editors. Reducing Harm to Patients from Healthcare associated Infection: The Role of
Surveillance: Australian Commission on Safety and Quality in Health Care, 2008.
• The suggested reference sets for values relevant to HAI microbiology requests and reports e.g. clinical reason for
request, testing method, need further investigation regarding completeness and options for representation on user
interfaces and within laboratory information systems, considering use of SNOMED CT, LOINC, new or existing clinical
reference sets.
0472
Nurse-Led CPAP Clinic for patients with Obstructive Sleep Apnoea Syndrome (OSAS)
Chung Leung Henry Poon, Yuet Kwai Chan, Shu Wah Ng, Yuk Yin Chong
United Christian Hospital, Hong Kong
Background
Obstructive Sleep Apnoea Syndrome (OSAS) is thought to be a cause of hypertension, ischemic heart disease, stroke,
and road traffic accidents. Prevalence surveys estimated that 4% of middle-aged men and 2% of middle-aged women
were affected by sleep apnoea. The disease is considered a public health hazard similar in impact to smoking. The
recommended initial treatment of choice is nasal continuous positive airways pressure therapy (CPAP). However,
compliance with CPAP is frequently inadequate, because of inconvenience and side effects CPAP. This underpins the
need for more effective management strategies for caring these patients, the Department of Medicine & Geriatrics
pioneers a Respiratory nurse-led CPAP clinic for patients with OSAS to improve the CPAP compliance, management and
provide quality care to these patients.
Objectives
1) To improve basic knowledge on OSAS and for CPAP therapy in OSAS patients; 2) To improve CPAP compliance for
patient with OSAS.
Methodology
The framework of the nurse-led clinic includes structure, process and outcomes.
Structure
The nurse-led clinic is run by very experience and well-educated respiratory specialty nurses. The independent roles of
the nurse are those planned, implemented, and evaluated by the nurse autonomously.
Process
The main functions of nurse-led CPAP clinic are identifying health care needs with the patient and improving CPAP
compliance of the patients. Patients are meeting predefined criteria will undergo a sleep study followed by therapy
initiation. Confirmation of investigation findings, evaluation of treatment, education and long term review are carried out in
nurse-led CPAP clinic. In the clinic, the nurse will explain to the patient/ significant others the reasons and importance of
the CPAP compliance, a serial clear and direct multi-media with audio-visual aided health education program will be
provided which including
1) Video show;
2) Demonstration on CPAP therapy;
3) Trail for CPAP machine;
4) Briefing session for CPAP rental/ purchase;
5) Information on a the trouble shooting, cleansing & maintenance and
6) Precautionary measures for CPAP users.
Hotline will be provided to the patients for health counselling and early follow-up arrangement.
Outcomes
The ongoing evaluations of nurse-led CPAP clinic intervention are to monitor the compliance with, predict the long-term
acceptability of CPAP therapy and assess the effect of CPAP therapy such as severity of sleepiness by Epworth
Sleepiness Score, compliance rate, troubleshooting or side-effects.
Results
We evaluated outcome in the 15 OSAS patients between July 2010 and December 2010. Basic knowledge on OSAS and
CPAP therapy were significantly improved, over 70% of those who undertook a trial of CPAP treatment continued at 3
months, with average compliance >5 hours per night. Statistically significant sustained improvement in sleepiness was
seen. Nearly all (98%) patients are satisfied with the services provided in the clinic.
Conclusion
The development of nurse clinic has demonstrated nurses’ commitment in the provision of quality patient care. Nurse-Led
CPAP Clinic is effective in improving the CPAP compliance, daytime sleepiness and providing quality care to those
patients suffering from OSAS. The Healthcare System also benefits through reduction of hospital admissions for related
cardiovascular diseases.
0475
The study of the satisfaction degree for family members in liver transplant intensive care unit on using video
visiting
Hung-Feng Chene, Menc-Fenc Chi, Chen-Ying Hsiu, Chee-Chien Yong
Kaohsiung Chang Gung Memorial Hospital, Kaohsiung,NIAO-SUNG, Taiwan
Objective
In these years, it emphasize the care for patients focus, only realize the expectation of the family members, it will be able
to provide the satisfied service. Thus, with this study, we try to realize the satisfaction degree and demand of family
members on video visiting and to take them as the reference for designing video visiting process and instructions.
Methods
In this study, it was take the cross-sectional research design research method , which is using strutted questionnaire on
data collecting. The questionnaire content will include: The basic information of sample, the satisfaction degree of family
members on video visiting, with 12 questions totally. The tool was passed with reliability and validity analysis, 66 persons
sampled from the family members of liver donor and recipients who were signed to liver transplant intensive care unit from
a medical canter in Taiwan. According to Five-point Likert Scale on scoring. With the higher scores, it means the
evaluation of satisfaction degree of family members on video visiting which is positive.
Result
The average age of the sample is 42 years old in this study. 66.7 % for female and 51.5 % is with junior college (under
level is included) . The couple relationship with patients is occupied 65.2% as most, with intensive care unit visiting
experience in other hospital which occupied 39.4%, the average hospital stay is 7.2 days, the average scores for patient
APACHE II is 14.95. And the top 3 for the satisfaction degree of family members is: Be able to talk with doctor in charge
to understand the patient’s situation at 4.2 points(85.0%), Nurses will take the initiative concern during the video visiting
process at 4.1 points (83.4%), satisfaction degree for the video visiting equipment 4.0 points (81.1%). The lowest 3 for
satisfaction degree is: The time arrangement for video visiting 2.9 points (59.3%), The order of video visiting 3.0 points
(60.2%) and to transfer something to patients 3.5 points (70.4%). The overall satisfaction degree at 3.72 points (75.2%).
And there are 58 family members (87.9%) said that they will recommend this hospital once there will still other members
need to stay in intensive care unit. With further study, 37 family members who is with the scores of APACHE II between
15-19 points (56.1%) is with the higher degree in overall satisfaction. 34 family members with education level in junior
college (included) is higher.
Conclusion
Only to understand the satisfaction degree and expectation of family members on video visiting will able to provide the
satisfied service. Besides, for fear that patients may be infected after the operation, video visiting is a visiting model which
is worth to encourage. With wonderful video visiting process and instructions, which can satisfied with the demand of family
members, and then to improve the quality of medical care and increase the satisfaction of hospital then.
0480
Taking an in-depth look at how to meet the newly hired nurses’ needs in dealing with workplace adjustment and
competence enhancement
1
2
2
2
Ju-Chun Chien , Wan-Ching Chao , Hwa-Nien Liu , Mei-Hua Sun
1
2
Oriental Institute of Technology, New Taipei City, Taiwan, Far Eastern Memorial Hospital, New Taipei City, Taiwan
Objective:
The purpose of this study was to examine discrepancies between preceptors and the newly hired nurses on the issues of
instructional effectiveness and workplace adjustment to facilitate the implementation of a nursing preceptorship program.
Methods:
The sample consisted of 317 registered nurses recruited from a medical centre in the northern part of Taiwan as they
participated in the Post-graduate Two-year Nursing Training Program. A total of 183 were newly hired nurses and the
rest (134) were preceptors.
By means of taking a semi-structured interview with 10 outstanding preceptors for a better understanding of their opinions
in implementing the Two-year Nursing Training Program, four instruments were used in this study: Clinical Preceptor
Teaching Performance Scale (CPTPC), Workplace Stressor Scale for Newly Employed Nurses (WSS), and the
Tennessee Self-Concept Scale: Second Edition for Adults (TSCS), and the General Self-Efficacy Scale (GSES). The
survey was taken in June, 2010. Specific instructions to complete CPTPC and WSS were as follows: I. As a preceptor,
please make self assessment on CPTPC, and to complete WSS from a newly hired nurse’s point of view. II. As a newly
hired nurse, recall an outstanding preceptor you have actually met to complete CPTPC.
The data were analyzed using descriptive statistics, t-test, MANOVA, etc.
Results:
The most workplace stressor highly rated by 183 newly hired nurses was “insufficient proficiency” (N = 72, 39.34%). The
second most workplace stressor was “not familiar with routine processes” (N = 36, 19.67%), and the third most workplace
stressor was “interpersonal adjustment” (N = 28, 15.30%). On the other hand, the preceptors also rated “insufficient
proficiency” as the most workplace stressor for newly hired nurses to deal with (N = 48, 35.82%). The second most
workplace stressor was “not familiar with routine processes” (N = 39, 29.10%), and the third most workplace stressor was
“lack of self-confidence” (N = 24, 17.91%).
As newly hired nurses, the most anticipated assistance from their preceptor(s) was “to enhance nursing competency” (N =
59, 32.24%). The second most anticipated assistance was “to give them more encouragements” (N = 33, 18.03%). The
third most anticipated assistance was “workplace adjustment facilitation” (N = 39, 21.31%). As preceptors, they expected
that the most helpful assistance to support the newly hired nurses was “to have more patience in instruction” (N = 32,
23.88%). The second most helpful assistance was “listening to their problems” (N = 26, 19.40%). The third most helpful
assistance was “to give them more encouragements” (N = 28, 20.90%).
According to the results of CPTPC, the newly hired nurses (M = 153.50, SD = 19.37) rated significantly higher scores than
the preceptors (M = 142.36, SD = 16.32) rated themselves (t(315) = 5.39, p = .00). The most discrepancy between the
preceptors’ rating and the newly hired nurses’ rating was “preceptor’s instructional skill”.
On TSCS, preceptors (M = 54.18, SD = 8.41) had significantly higher self-concept than the newly hired nurses (M = 51.92,
SD = 8.87). However, there was no significant difference between preceptors and newly hired nurses on the result of
GSES.
Conclusions:
The study revealed that it should take mutual efforts for preceptors and newly hired nurses to enhance the effectiveness
of the nursing preceptorship program. The rating discrepancy between preceptors and the newly hired nurses for each
item in the CPTPC can be a very useful indicator for preceptors to make progress. Although the preceptors might highly
recognize the main workplace stressors for newly hired nurses to deal with, they were less capable of providing timely
assistance to them. In order to increase the newly hired nurses’ professional competencies, there is a need to focus on
enhancing preceptors’ instructional skill.
0482
Framework for a future national healthcare performance measurement system in Norway
Liv Helen Rygh, Jon Helgeland, Geir Bukholm
Norwegian Knowledge Centre for the Health Services, Oslo, Norway
Objective: The aim of the present work was to conduct an informed and guided development of a framework for a
national healthcare performance measurement system with high societal and professional legitimacy and credibility.
Methods: Norway is among the OECD countries with highest per inhabitant expenditures on health care, but the health
care system seems to deliver average quality, as shown in various international comparative reports. There is an urgent
need to monitor by evidence-based methods how the Norwegian health care system is performing. The work was based
on a previous systematic inquiry and analysis into underlying concepts and content of selected performance
measurements systems at the international and national levels. Following this up, and taking the Norwegian context into
consideration, we conducted a focused analysis of strategic goals and information needs of national health authorities and
relevant stakeholders, including professional and institutional providers and healthcare users. During this phase a
multidisciplinary academic research group (n=12) formed a structure for an interactive process, chaired by the Norwegian
Knowledge Centre for the Health Services. To support the decision basis for the group, supplementary literature searches
on existing theory and international experiences were performed. The choices for the framework were made by the
research group through a consensus approach. The proposals forming the framework and their basis were subsequently
published and discussed with key informants from relevant agencies and organizations.
Results: There was a broad agreement of developing an ambitious performance measurement system: highly relevant in
a health policy context and applicable for realistic public comparisons at the local, national and international level (when
relevant). The main perspective should be political governance and learning (accountability), and the primary audience
national health politicians and authorities, healthcare managers, as well as the lay public. It should be designed to be an
important part of quality improvement initiatives within the healthcare system as a whole, including primary care. A
conceptual model based on the OECD HCQI framework was chosen, with focus on the following quality dimensions:
Effectiveness/Safety/Responsiveness/ Patient centeredness/ Accessibility. The system should be developed with
stringent methodology, including assurance of data validity and quality, and with emphasize on outcome indicators and
indicators that reflect the patient and consumer perspective. Other key elements of the framework include ethical and
societal perspectives: The prioritization and selection of clinical or generic domains should to be based on fair,
deliberative processes which are fully transparent and based on preselected criteria: (i) importance of the medical
condition and the implications of the clinical intervention, (ii) particular resource-intensive investigation/diagnostics,
treatment and/or follow-up, (iii) particularly at risk/vulnerable patient pathways, (iv) lack of scientific consensus with regard
to treatment/lack of experience associated with the introduction of new technology. Furthermore, consensus processes
should be used in all relevant steps in the systematic selection and evaluation processes to ensure scientific and
professional aspects, as well as health policy and value-related aspects. The system should be based on existing data
sources (in patient administrative systems, medical records, laboratory systems, etc.), as well as on prospectively
collected data when necessary, based on the purpose of the indicator sets.
Conclusions: The chosen procedure has proven valuable for designing a framework for a national healthcare
performance system that is based on internationally recognized procedures and norms. The framework can form an
overarching strategy and articulate guiding principles for both value-based and professional priorities. Considerable
acceptance and support has been expressed by the professional and health policy levels both for the procedural
approach and the resultant framework. Based on our proposals, a framework has been endorsed by Norwegian health
authorities, with the Knowledge Centre as competent institution responsible for the development and analysis of the
national indicators.
0483
Enhance the home care capacity of primary caregiver to patients undergoing flap for reconstruction after head
and neck cancer surgery.
YEN JU YANG, I PING LEE, HUI CHUN CHAO
CHI MEI MEDICAL CENTER, Tainan,Yongkang Dist., Taiwan
Abstract：The project aims to enhance the home care capacity of primary caregiver to patients undergoing flap for
reconstruction after head and neck cancer surgery.
Methods：The report was guided by the analysis of current guidance on nursing home care capacity of nurse and that of
primary caregiver home care knowledge and skills. The use of fishbone diagram summarized that (1) lack of guidance for
nurse on nursing home care capacity (2) No discharge planning and home care instruction procedures (3) lack of
guidance to home care nursing supplies (4) lack of home care manual (5) lack of checking the quality of nursing
instruction sheet (6) lack of evaluation form about capacity of primary caregivers for home care. Therefore, the
implementation of the ad hoc group set up (1) regular classroom teaching, seminar for case studies and technical
operations and exercise from time to time (2) to set standards for discharge planning and home care instruction
procedures (3) home health care box set (4) Production of home care manual (5) sheet of production to check the quality
of nursing instruction (6) Production of evaluation form about capacity of primary caregivers for home care to improve the
ability of primary caregivers for home care.
Results：The duration from December 2009 to April 2010, the use of (1) head and neck tumor surgery 『check the
quality of nursing instruction sheet』 audit the effectiveness of nursing care and patient care (2) "head and neck tumor
surgery capacity of primary caregivers of home care evaluation Table" is the guidance and assessment on the 13 primary
caregivers to improve results for the primary caregiver the integrity of the home care capacity increased from 27.78 % to
91.27 % .
Conclusions：Throughout the improvement of this project,and by setting standards of the process which not only
establish a therapeutic partnership of nursing staff, patients and their caregivers, but also enhance the quality of nursing
guidance after the practical application. Then, it’s helpful to the implementation of a comprehensive management
for ”head and neck cancer and flap reconstruction cases”. It increases the correct knowledge of disease caring for
patients and their families and more effective of primary care providers to enhance the integrity of home care capacity, so
that helps patients and their families in life as early as possible after returning home. The follow-up treatment and care of
such cases are very lengthy processes; the use of the medical team at the clinic is recommended and also keeps tracking
of the implementation of the case.
0485
Inter-professional clinical handover in the emergency department: tools for patient safety
Bernice Redley, Mari Botti, Tracey Bucknall, Megan-Jane Johnstone
Deakin University, Burwood, Victoria, Australia
Inter and intra-professional communication in the form of clinical handover occurs in the Emergency Department (ED)
when there is a change in staff responsibility for care, or in response to change in a patient’s clinical condition. These
transitions are points in care where serious communication errors are most likely to occur and where it is essential to
understand and improve clinical team performance.
Objective
The purpose of this study was to examine ED handover content and behaviours to inform development of a tool to
measure the quality of team performance during clinical handover in this complex, high risk setting. Three specific aims
were to: 1) Identify current clinical handover patterns and processes that relate to transfer of responsibility for patient care
in the ED; 2) Identify the core information regarding the patient, environment or equipment that should be transferred to
ensure quality of care and patient safety and 3) Identify behavioural dimensions of team communication that may affect
quality of care and patient safety.
Methods
Inter-and intra professional communication during clinical handover was examined at two hospital EDs, one public and
one private. Naturalistic enquiry was used to examine the complexity of clinical handover, including interrelationships with
clinical governance, risk management and quality improvement. Data included observations of ED handover practice by
two observers; one familiar with the environment who observed tasks and content of handover, and one unfamiliar with
the environment who observed the interpersonal behaviours associated with communication during handover. In addition,
handover content was audio-taped handover and focus group interviews were conducted with key stakeholders.
Naturalistic enquiry methods were used to analyse the combination of qualitative and empirical data to describe in-depth
the quality and safety of inter-professional communication during clinical handover in the ED in context and to identify the
core concepts for handover evaluation.
Results
Analysis of medical and nursing handovers related to 80 ED patients at two hospitals revealed the key concepts related to
the quality of ED handover. All the handover events observed were between clinicians of the same professional groups
such as nurse-to-nurse and doctor-to-doctor at a change of shift. Key aspects of handover that affected the quality of
communication were: the environment in which handover processes occur, current tools used to assist handover, patient
and family role in handover, and current strategies in handover used as opportunities to minimise risk. Significant gaps in
inter-professional communication related to handover within the ED were identified. Inter-professional communication and
handover was observed to occur ad-hoc, with limited structure and high variability between events Observations revealed
both good practices and those that contributed to gaps in care and increased risk for error, particularly related to interprofessional communication.
Conclusions
Observational methods are well recognised as the ‘gold standard’ for measures of quality improvement, yet a rigorous
method for the development of such tools is lacking. The primary outcome was a framework for an observation tool for
assessing the quality of inter and intra professional communication during transitions of care in the ED. Such a framework
is an essential foundation for future research to establish links between handover practices and patient outcomes and
intervention studies to improve team performance and communication at ED handover and subsequent patient outcomes.
Added benefits from the process of tool development were to promote local ownership and support clinician engagement
in quality improvement.
0487
A clinical audit on the process performance of smoking cessation in a primary care clinic in Hong Kong
Sze Man Cheung, Man Kuen Cheung, Jun Liang
Tuen Mun Hospital, Hospital Authority, New Territories, Hong Kong
Objectives:
To audit the process of management of smoking cessation in a primary care clinic; to investigate the reasons for
deficiency of management; to identify strategies to overcome the deficiency in management and implement changes and
to re-evaluate the performance after applying these changes.
Methods:
Definition of standard:
Inclusion criteria: All smokers aged 16 or above (defined as born on year 1991)
Exclusion criteria: Ex-smoker : patient who does not smoke for more than 4 months
Criteria
Standard
I
Annual documentation of number of cigarettes smoked daily
100%
II
Annual assessment of smoker’s motivation
100%
IIIa
Discussing smoking cessation annually
95%
IIIb
Offering follow up for motivated smokers
95%
IV
Recommending nicotine replacement therapy for motivated smokers
who smoke >=10 cig/day
95%
Data collection:
st
1 cycle data was drawn in the calendar year 2006, patients who had been coded with ICPC2 coding P17 had been
nd
drawn. 2 cycle data was drawn for the period Sept 2007 to Aug 2008 after an implementation of change for 3 months.
The whole population of smokers was studied. No sampling was needed.
Implementation of Change:
Changes including both patient and staff education to increase their awareness of smoking cessation and smoking
related diseases.
Posters and pamphlets and smoking cessation cards are made available in the clinic as educational materials.
The hazards of smoking and benefit of smoking cessation were discussed in the clinic meeting.
Results:
In the first cycle, 160 patients were identified, 16 of them were excluded because they were no longer smokers. 144
eligible patients were studied. The prevalence of smokers was 2.5%.Their medical records were reviewed and recorded
and compared with the standards, all criteria were below standards.
In the second cycle, 134 patients were identified, with 119 patients remained eligible after applying exclusion criteria.
Only criterion I met the pre-set standard, but most of the performances in the second phase had improvements.
Conclusion:
The management of smoking patient was found to be inadequate in the first cycle and all of the criteria improved after
implementation of changes; both medical and nursing staff understood more about the patient benefit of smoking
cessation and intervention skills. The smoking cessation rate could be further increased as a result of better process
performance. Further audit cycles are necessary to measure the continuity of the process performance and outcome of
smoking cessation.
0490
Time from breast cancer diagnosis to initiation of therapy as a quality indicator
Doron Comaneshter, Jacob Dreiher, Haim Bitterman, Arnon D. Cohen
Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
Objective: The goal of the study was to develop quality indicators assessing the proportion of patients with breast cancer
initiating therapy within 30, 45, and 60 days following the diagnosis in subgroups (by age, ethnicity, socioeconomic status,
etc.), to examine time trends over the last two years, and to identify factors associated with delayed treatment.
Methods: All adult women (≥19 years old) enrolled in Clalit Health Services (CHS), the largest healthcare provider
organization in Israel, who were diagnosed with breast cancer during 2008–2009 were included in the study. The date of
diagnosis was identified from Clalit's registry of chronic illnesses. We identified the dates in which
mastectomy/lumpectomy, radiotherapy, or chemotherapy was initiated. Background variables included age, marital status,
ethnicity (Jewish vs. non-Jewish, socioeconomic status, employment pattern of the primary care physician (hired vs. selfemployed), place of residence (urban vs. rural), Charlson's comorbidity index, and total number of visits to the primary
care physician in the year preceding the diagnosis. We assessed the proportion of patients initiating therapy within 30, 45,
and 60 days of diagnosis, out of all patients initiating therapy within 6 months of diagnosis, in various subgroups of the
study population. Logistic regression models were used to explain the failure to initiate therapy within those periods.
Results: 4,548 women were included in the study (mean age: 60.8±13.1 years). 62.9% were married, 48% were Israelborn, 20% had a Charlson's comorbidity index >3. 70% were from a medium-high socioeconomic status. The proportions
of breast cancer patients initiating therapy within 30, 45, and 60 days were 53.0%, 69.4%, and 81.5%, respectively. These
figures were stable during the four six-months periods included in the study. In a multivariate model, failure to initiate
therapy within 30, 45, or 60 days was associated with age >54 years and significant comorbidity (Charlson's comorbidity
index>0 prior to diagnosis). No other predictors were identified,
Conclusions: Initiation of therapy for breast cancer patients in Israel is delayed in a significant proportion of cases,
especially in older women and those with chronic comorbidities. Efforts should be made to decrease the proportion of
delayed therapy for these women.
0494
Multidisciplinary low-cost program on rapid improvement in prostate biopsy service
Lap Yin HO, Theresa Li, Steve Chan
Queen Elizabeth Hospital, Hong Kong
Objective
Prostate biopsy service in our hospital was suboptimal: pitfalls for medical errors were identified and rectified.
Background
9 anatomical specimen rejection in urology were reported July – Dec 2009, mostly because of absence of specimen label,
unclear labelling or mismatch of specimen form and label.
Methodology
Root cause analysis was carried out, the whole procedure steps were reviewed, and the following gaps were identified:
a. excessive patient movement between biopsy suite and observation day ward
b. patient identify was not double-checked before the biopsy
c. urologists performing the procedure were not assisted by a trained person
d. biopsy procedure and labeling were not standardized among different urologists
e. presence of specimen were not cross-checked.
f. Specimen label and request form were not cross-checked.
Improvement implementation was carried out March to June, 2010.
a. First phase involves standardization of biopsy technique, request form, label and procedure.
b. Second phase improvement by assigning nursing staff for value added process including specimen confirmation,
cross-checking and time-out procedure.
c.
Finally, the whole workflow and environment were improved by relocating the procedure from the day ward and
urology side ward to Day surgery Centre after well planned logistics and staff training.
Results
Anatomic specimen rejection were reduced to zero (May 2010 to Jan 2011) after implementation of improvement. Patient
safety was enhanced, with improved monitoring and identify cross-checking. Wastage was also reduced in terms of
waiting and motion because the whole procedure, including waiting and discharge were carried out in one location. The
cost of the whole project was negligible.
Conclusion
With multi-disciplinary input and careful planning, significant service improvement can be achieved at a low cost. Patient
safety is enhanced.
0496
Study on Improvement of Maintaining Blood Phenytoin Levels within Therapeutic Range for Patients with
Epilepsy
Yu-Yi Kao, Chia-Wen Wen, Chu -Chen Huang, Yu-Li Lin
Chang-Gung Medical Foundation, Taoyuan, Taiwan
Objective
Epilepsy is one of the post-neurosurgical predispositions. Phenytoin has been commonly prescribed as an antiepileptic
agent to treat and prevent most types of seizure disorders; however, the therapeutic range is narrow. Overdosed
phenytoin in serum leads to neurological adverse effects such as confusion or coma that can consequently increase
mortality. In contrast, epilepsy-related sudden death may be attribute by subtherapeutic dose of phenytoin. Therefore, it is
extraordinarily important to maintain the therapeutic range of blood phenytoin levels. The aims of this study is to improve
the nurses’ knowledge and competency for maintaining the blood phenytoin levels in patients with epilepsy.
Methods
This study was conducted in September, 2009. All data were collected by self-designed, structured checklist and practical
observations. There were only 26.1% of the patients receiving phenytoin whose blood phenytoin levels within the
therapeutic range, whereas of those, 52.5% were lower and 21.4% were higher than the therapeutic range. The results
were attributed to the following reasons. Firstly, only 67.36% of nurses had adequate knowledge towards phenytoin. Two
items identified with lowest scores including accurate timing for blood sampling and examination after phenytoin
administration, and medications caused drug interactions with phenytoin. Secondly, note of drug administration time was
recorded in only 59.7% of phenytoin test order. The rate of correct timing to collect blood sample was only 85%. Low
scores were resulted from mismanagement for phenytoin administration and monitoring.
Two strategies were implemented for improvement in October of the same year, including providing continuing education
to improve knowledge and attitude of phenytoin administration among nurses as well as defining the administration
regimen and drug monitoring standard procedures for prescribing phenytoin according to specific clinical conditions. The
revised procedures consists of blood sampling after administered intravenously and time elapsing between feeding and
administration should be greater than or equal to 2 hours. To validate the latest description of administration time, the
default inquiry of timing was simultaneously associated with the computerized issue of physicians’ orders. The description
of 2-hour elapsing between feeding and phenytoin administration was also clearly noted on medication administration
record to avoid the impacts of enteral feedings and drug interactions.
Results
The evaluation conducted in June 2010 demonstrated the following results. Firstly, the knowledge on phenytoin was
increased from 67.36% to 100.00% among nurses. Secondly, the rate noting the administered time on test request rose
from 59.7% to 100.0%. Thirdly, the accuracy of timing to collect blood sample was improved (85% vs. 100%). Finally, the
rate of phenytoin maintained within therapeutic range was elevated from 26.1% to 46.3% as blood concentrations of
phenytoin were monitored. The rate of subtherapeutic dose was decreased from 52.5% to 36.3% while the overdosed
rate was lowered to 17.1% from 21.4%. Better efficacy and lower rate of adverse effects have been achieved by putting
on more efforts on maintaining the therapeutic range of phenytoin,.
Conclusions
Increased mortality may attribute to either overdose or subtherapeutic levels of phenytoin in blood. Prior to the
improvement project, the nurses did not have sufficient knowledge of drug monitoring and drug interaction. Nor the
standard procedures were available for appropriate use of phenytoin. By improving the knowledge of phenytoin as well as
revising the standard procedures of drug administration and monitoring, the nurses have learned how to avoid adverse
effects derived by either over or subtherapeutic dose. Subsequent improvement on the quality of post-neurosurgical care
has been also achieved.
0497
Educational disparities in quality of diabetes care in a universal health insurance system
1
2
Young Kyung Do , Karen Eggleston
1
2
Duke-NUS Graduate Medical School, Singapore, Stanford University, Stanford, USA
Objective: To investigate educational disparities in care process and health outcomes among patients with diabetes in
the context of South Korea's universal health insurance system.
Methods: Data from a nationally-representative and population-based survey, the 2005 Korea National Health and
Nutrition Examination Survey, were used. This study focused on respondents aged 40 or older who self-reported prior
diagnosis with diabetes (N=1,418). Main outcome measures were seven measures of care process and health outcomes,
namely 1) Receiving medical treatment for diabetes, 2) Ever received diabetes education, 3) Received fundoscopic
examination in the past year, 4) Received microalbuminuria test in the past year, 5) Having activity limitation due to
diabetes, 6) Poor self-rated health, and 7) Self-rated health on a visual analog scale. Bivariate and multiple regression
analysis was conducted to analyze the association between each of these seven outcome measures and individual
socioeconomic characteristics.
Results: Except for receiving medical care for diabetes, overall process quality was low, with only 25% having ever
received diabetes education, 39% having received a fundoscopic examination in the past year, and 51% having received
a microalbuminuria test in the past year. Lower education level was associated with both poorer care process and poorer
health outcomes, whereas lower income level was only associated with poorer health outcomes.
Conclusions: While South Korea's universal health insurance system may have succeeded in substantially reducing
financial barriers related to diabetes care, the quality of diabetes care is low overall and varies by education level.
System-level quality improvement efforts are required to address the major weaknesses of the health system, thereby
mitigating socioeconomic disparities in diabetes care quality.
0499
Good practices in nursing to ensure the patient safety
Ana Rojas-de-Mora-Figueroa, Antonio Almuedo-Paz, Marta Vazquez-Vazquez, Vicente Santana-Lopez
Andalusian Agency for Healthcare Quality (ACSA), Seville, Andalusia, Spain
Objective:
To analyze interventions performed by nurses following the Andalusian Public Healthcare System Accreditation Process,
in order to ensure the safety of their patients.
Methods:
1. Subject of study: Nurses following the Accreditation Process of their Professional Competences.
2. Scope: Public Health System in Andalusia.
3. Timeframe: October 2007 - February 2011
4. Sample size: 2,450 patients, treated by 1,225 nurses: 1,028 in Hospital and Special Care; 410 in Surgery Center; 234
in Childcare; 194 in Ambulatory Care; 30 in Mental Health; 8 in Palliative Care; 94 in Pre-hospital Emergencies; 452 in
Primary Healthcare
5. Type of design: Descriptive analysis
6. Instrument: Accreditation program of professional competences. This program, created in 2005, considers
accreditation as a voluntary process, based on a portfolio model, where professionals provide information about the
welfare work they perform in their jobs.
Among the information that should be provided, can be found that one related to good practices: The professional carries
out different activities to avoid adverse events and to increase safety in their professional performance. Following NIC
interventions, performed by nurses, were analyzed: 6486 Environmental Management: Safety; 6654 Surveillance:
Safety; 7170 Family Presence Facilitation; 5380 Security Enhancement; 6680 Vital Signs Monitoring; 6540 Infection
Control; 6200 Emergency Care; 6160 Crisis Intervention; 3200 Aspiration Precaution; 6490 Fall Prevention; 6420 Area
Restriction; 6580 Physical Restrain; 0940 Traction/Immobilization Care; 0960 Transport.
Results:
95.31% of patients were assessed in a structured way by nurses. From these, in 24% of occasions, Marjory Gordon's
functional patterns were used, while in 76% of occasions basic needs assessment of Virginia Henderson were used.
12,235 interventions were performed to ensure safety on 2,450 patients, which means an average of 5 interventions per
patient. Nurses who performed more interventions per patient to ensure safety were those from Surgery Center (3,401
interventions on 410 patients, which means 8.29 interventions per patient).
The most frequent NIC intervention performed by nurses was 6490 Fall Prevention, on 1,736 patients (70.86%), followed
by intervention 6486 Environmental Management: Safety, performed on 1,549 patients (63.22%).
On 66.77% of patients, nurses recorded a positive development of performance indicators.
Conclusions:
Nurses on an Accreditation Process focus their professional practice on ensuring patient safety, after a structured
assessment.
Accreditation Programs on Professional Competences are a valuable source of information regarding the development of
good practices among health professionals.
The absence of interventions to ensure other basic safe practices may be due to the format of data collection, with preset
items, which suggests the need for restructuring this form.
0502
Project to Reduce Pain Scale Scores During Intravenous Cannulation in Children
Wang Jing Huei, Liao Ciou Huei, Lu Chun Ya, Lee Chang Ching
Chi Mei Hospital, Tainan, Taiwan
Introduction
Young hospitalized children often exhibit refusal behavior and negative emotional reactions such as crying and resistance
when intravenous injection is given due to being limited in motion by force. The more the children resist, the longer the
duration is and the more attempts are made. The pain and stress increase as the duration of injection increases, which
not only cause physical and emotional damage to the children but also make the families weep along and complain or
give up treatment due to misunderstanding. The aim of this project is to reduce children’s pain scores during intravenous
cannulation by 10%.
Methods
According to the results of empirical analysis, we 1) developed a behavioral pain assessment scale for children. 2)
implemented guidelines of care for pediatric intravenous cannulaiton to give direction for nursing practice, monitor results
of the assessment and for the application of the following measures: (A) preparing materials and providing treatment
environment that are tailored according to patients’ age and properly communicating with patients and families with visual
aids such as educational film on IV infusion procedure before the injection; (B) diverting patients’ attention with
therapeutic play during the injection; and (C) using various soothing methods or rewards as ways to calm the children
after the injection. 3) created health educational pamphlets on information about IV infusion therapy and the use of
infusion pump. 4) added more colors to the treatment room and painted cartoon characters on the wall to make it a less
stressful place for already anxious children. 5) purchased more attention driven items such as sound and light toys,
stickers or TV sets. 6) provided on-the-job training sessions on techniques and care of IV therapy. 7) fastened straps to
the joints of the limbs, instead of limiting children’s movement by force, allowing the patients to decide site and position
they prefer for injection.
Results
During the period from February to April 2011, a reduction of 10% in pain scores was achieved, reaching the goal of the
project.
Conclusion
Attention-diverting strategies tailored to children based on their age and applied pre-, during, and post-injection, such as
teaching deep breathing skills, offering therapeutic touch, playing cartoons on the TV and providing rewards, were proved
to be effective in reducing pain sensation during the intravenous cannulation. The project will be extended to other
departments that also admitted young patients.
0503
Quality assessment of diabetes care: looking at measures of adequate and timely actions
Grigory Sidorenkov, Flora Haaijer-Ruskamp, Dick de Zeeuw, Petra Denig
University of Groningen/University Medical Center Groningen, Groningen, The Netherlands
Objective:
To assess quality of diabetes care by looking at the full clinical pathway of risk factor management and at timeliness for
actions, and determine optimal time windows for such quality assessment.
Methods:
Adequate quality assessment of processes of care is hampered by the fact that often only one action is evaluated in
isolation. In addition, the time window for evaluating such an action is often not specified. A more appropriate assessment
of risk factor management would be to include the full clinical pathway: (1) risk factor test, (2) treatment intensification
when indicated, and (3) response to treatment evaluation, and the (relative) timing of these actions. A cohort study was
undertaken in 100 general practices in the Netherlands in 2007-2008. Percentages of patients adequately managed
regarding HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin-creatinine-ratio (ACR) were
calculated. Strict and wide time windows for each step of care were defined using previous studies and guideline
recommendations, ranging from 14-180 days. Percentages of patients receiving adequate management within different
time windows were compared using odds ratios (OR) and 95% confidence intervals (CI). Optimal time windows were set
based on the distribution of patients receiving actions over time.
Results:
In the full clinical pathway, 64-67%, 42-44%, 43-44% and 38-37% patients were adequately managed regarding HbA1c,
SBP, LDL-C and ACR using respectively strict and wide time windows. For management of HbA1c and SBP, the chance
of being assessed as adequately managed were significantly higher when using wide time windows (OR 1.12; 95% CI
1.06-1.189; OR 1.06; 95% CI 1.01 to 1.12). For management of SBP and ACR, the assessments did not differ
significantly different when using wide or strict time windows. Regarding the step of treatment intensification, 11-18%, 79%, 5-9% and 6-6% patients received prompt (within 30 days) or lenient management (within 120 days, i.e. including the
next regular visit) for elevated HbA1c, SBP, LDL-C and ACR levels. Regarding the step of treatment evaluation, timely
reaction was seen in 68%, 50%, 42% and 74% patients in response to changes in glucose-lowering (GL),
antihypertensive (AH), lipid-lowering (LL) and renin-angiotensin-aldosterone-system inhibitors treatment. Too early
evaluation of treatment response was observed in 20%, 23% and 2% patients for GL, AH and LL treatment changes. Late
evaluation was seen in 26%, 16% and 14% patients in response to GL, AH and LL treatment.
Conclusions:
Looking at the full clinical pathway showed that the quality of diabetes care assessed as a whole is better than for the
isolated steps. However, quality of care assessed for the full clinical pathway is still suboptimal, especially for
management of blood pressure, lipids and albuminuria. Allowing for the next regular visit with the accompanying
treatment related actions up to 120 days significantly increases the assessed quality of care, and is proposed as fair
assessment of clinical practice. Considering wider time windows, up to 180 days, only slightly changes the assessment
for HbA1c and SBP, and is not recommended for clinical reasons. Quality assessment of response to glucose-lowering
and antihypertensive treatment is affected by tests performed too early which thus needs to be incorporated in the quality
measures.
0504
Engaging Continuing Education and Quality Improvement Professionals in LEAN Healthcare Quality
Improvement
1
1
2
1
Deanna Willis , Julie Vannerson , Zev Winicur , Charles Clark
1
2
Indiana University School of Medicine, Indianapolis, IN, USA, CME Enterprise, Carmel, IN, USA
Background:
A live, in-person, continuing medical education workshop was developed to teach quality improvement techniques using
LEAN quality improvement pedagogy, including didactic presentations, classroom simulations, and world café learning
format. The live workshop, A Bridge to Quality: Engaging Continuing Education and Quality Improvement Professionals
in Healthcare Quality Improvement, was held in Phoenix, Arizona; Indianapolis, Indiana; Miami, Florida; Madison,
Wisconsin; and Nashville, Tennessee.
Methods:
Attendees were offered the opportunity to volunteer to take an outcome survey 6 weeks after the course offering. The
outcomes survey looked at whether or not the attendees reported making a change in their work activities or environment
based on the material they learned in the course. To assess the impact of the educational activity on changes in
performance (Moore's outcomes level 5), learners were asked via an opt-in question on the evaluation form to participate
in an online follow-up outcomes survey six weeks post activity. No outcomes data are reported for the Miami activity
because no participants opted in to receive a follow-up survey. To assess the impact of the educational activity on
changes in patient health (Moore's outcomes level 6), some additional data were gathered through the Madison and
Nashville outcomes tools. Furthermore, ongoing data collection will continue for one year post activity through the
initiative Web portal (www.bridgetoquality.com). The Madison and Nashville tools collected, and the Web portal will collect,
data on healthcare professional (HCP) engagement in quality improvement (QI), number of QI projects, and changes in
performance measures.
Results:
Of the 171 learners who attended the workshops, 22% (38) opted in to receive an online outcomes survey, and 8% (13)
completed the outcomes survey. At six weeks post activity, 86% of the survey respondents at the Madison and Nashville
activities reported that they were still able to achieve four out of the five learning objectives, and 100% reported that they
were able to "Discuss the relationship between the planning, implementation, and evaluation stages of CME and the
iterative steps of both QI and performance improvement (PI) processes." This compares to a range of 72-90% who
agreed that objectives were met on the postactivity evaluation and suggests that knowledge and skills in these areas were
maintained or increased after the activity, although the relatively lower number of responses to the outcomes survey
precludes firm conclusions. Compared to 81% of evaluation respondents who said they intended to make changes in their
healthcare institution as a result of the workshop, only 38% percent of the outcomes survey respondents reported that
they made changes thus far. The low number of outcomes respondents makes it difficult to draw conclusions, but many
respondents who indicated that they had not made changes in their practices reported that there had not been enough
time to make changes, suggesting that longer follow-up and possibly additional reinforcing interventions could be helpful.
Eighty-six percent (six out of seven) of the outcomes survey respondents at the Madison and Nashville activities reported
that they had shared the presentation material with others and would continue to share information in the future. Fortythree percent anticipate a future increase in QI projects at their institutions, and 29% anticipate a future increase in
healthcare provider engagement in QI projects.
Twenty-nine percent reported an increase in performance measures and 29% reported improvements in patient health as
a result of the training. Many reported that they did not know if improvements had occurred in these areas, or that such
improvements were not applicable to their situation.
Conclusions:
The data suggests that perhaps those who attended (or at least those who responded to the outcomes survey) tended to
not be the ones who could ascertain quality outcome data in their institutions, and that in addition to conducting longerterm follow-up, future strategies to encourage more collaboration within institutions and/or to obtain outcomes from
different sources may yield more data.
0511
Using Private Cloud Concepts to Improves ICU Admission Services
Shin-Jing Huang, Pa-Chun Wang, Wen-Jing Chen, Shu-Lin Guo
Cathay General Hospital, Taipei, Taiwan
Objective:
In order to improve the efficiency of ICU admission services, through process re-engineering, we established a webbased, on-demand ICU bed request system using the private cloud computing.
Methods:
A multidisciplinary team was organized in August 2009. We used the healthcare failure mode and effect analysis (HFMEA)
to analyze the intensive care unit admission process. Based on the recommendations from HFMEA, a web-based, ondemand ICU bed request system (a private cloud) was established with aims to improve ICU admission service and care
quality. In order to evaluate the effects of this system, structured questionnaires were used to measure the satisfaction of
patients and managers. Indicators including care quality, occupancy rate, turnover rate, average waiting time for
admission, average length of stay, and the rate of unplanned readmission to the ICU, are reported.
Results:
The critical failure modes in the ICU admission procedure were identified: (1) no transparency of ICU bed control. (2) the
admission process was delayed, (3) patient’s emergent status can’t be recorded in time, and (4) the prioritization of
patients for admission was difficult. According to weak points identified from these analyses, a web-based, on-demand
ICU bed request system was established. Physicians can register ICU admission request on line, and the APACHEⅡ
scores are automatically generated using cloud computation technology. Furthermore, physicians can update a patient’s
condition on-line. System managers can prioritize waiting list based on patient’s emerging clinical data. Handling
processes are exclusive.
This web-based, on-line ICU bed request symptom was completed in November 2010. According to the questionnaire
filled out by patients and families, the satisfactions of patients improved significantly. Our preliminary data show that
occupancy rate, average waiting time for admission, average length of stay, and the rate of unplanned readmission to the
ICU all significantly improved (P<0.05).
Conclusions:
Through process reengineering, we established an automated ICU admission mechanism. The private cloud-type request
system proved to be effective in reducing resources wasting and staff loading.
0513
Efforts to Reduce Door-to-Balloon Time in Acute ST-Elevation Myocardial Infarction: Results from 15 Primary
Percutaneous Coronary Intervention Centers in Taiwan
2
2
1
1
Jun-Jack Cheng , Su-Kiat Chua , Hsun-Hsiang Liao , Ian Chen
1
2
Taiwan Joint Commission on Hospital Accreditation(TJCHA), Banciao District, New Taipei City, Taiwan, Shin Kong Wu
Ho-Su Memorial Hospital, Taipei City, Taiwan
Objective:
The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance was associated with
increased likelihood of patients with ST-elevation myocardial infarction (STEMI) received primary percutaneous coronary
intervention (PPCI) within 90 min of hospital presentation.
Methods:
The Taiwan D2B Alliance, launched in July 2009 by Taiwan Joint Commission on Hospital Accreditation, sought to
achieve the goal of having 75% of STEMI patients receiving PPCI within 90 min of hospital presentation. We enrolled 15
PPCI centers across Taiwan, from July 2008 to February 2010. The D2B Alliance conducted several strategies and tools
to reduce D2B times, including: 1) activation of the catheterization (cath) laboratory by emergency physicians; 2) singlecall activation of the cath laboratory; 3) cath team is available within 30 min of being paged; 4) standardized protocol and
drug package for STEMI in Emergency Department (ED); 5) single cath devices package; 6) prompt (within 1 week) data
feedback to PPCI staff; 7) senior management commitment; 8) team-based approach to D2B improvement efforts. We
examine changes in D2B times before and after the launch of the D2B Alliance.
Results:
A total of 1,386 patients, at 15 PPCI centers from July 2008 to February 2010, were included in our analysis. Out of the
1,386 patients, 781 and 605 were enrolled before (from July 2008 to June 2009) and after (July 2009 to February 2010)
the launch of the D2B Alliance, respectively. Compared with those enrolled before launch of the D2B Alliance, the
following interval were improved significantly after launch of the D2B Alliance: 1) the time of underwent electrocardiogram
in ED (17.0 ± 16.6 min vs. 7.4 ± 4.7 min, p = 0.04); 2) the time of the diagnosis of STEMI (24.0 ± 18.2 min vs. 8.7 ± 6.1
min, p = 0.01); 3) the time of the cath team is available after being paged (27.1 ± 10.6 min vs. 17.6 ± 8.5 min, p = 0.03); 4)
duration of patients stay in ED (78.1 ± 36.5 min vs. 53.9 ± 15.0 min, p = 0.04); 5) interval of patients transport from ED to
cath laboratory (25.3 ± 27.6 min vs. 7.7 ± 3.1 min, p = 0.03); 6) mean D2B time (128.8 ± 42.9 min vs. 85.7 ± 19.0 min, p =
0.002); and 7) medium D2B time (110.5 ± 31.0 min vs. 86.4 ± 33.3 min, p = 0.05). No statistically significant differences
were noted in the following interval before and after launch of the D2B Alliance: 1) the time of arrival of cardiologists in ED
(9.9 ± 8.4 min vs. 10.2 ± 7.4 min, p = 0.94); and 2) the interval of cath laboratory door to balloon time (27.5 ± 8.0 min vs.
25.0 ± 7.1 min, p = 0.41). Before launch of the D2B Alliance, 37.3% of patients received PPCI within 90 min. This
numbers increased monthly during the period of joining the D2B Alliance, and achieved 82.4% (p < 0.001) in Feb. 2010
Percentage of patients received
PPCI within 90 min
Figure. Percentage of STEMI patients with D2B time within 90 min, from July 2008 to February 2010.
75%
The D2B Alliance
Conclusion:
We found significant improvements in D2B times among the 15 PPCI centers after the launch of the Taiwan D2B Alliance.
In addition, the D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by the end of
the study. The recommended strategies and tools provide important factors for improvement of D2B times.
0516
Improving the Follow-up rate After the Abnormal Pap Smears Screening
Shu-Feng Hsu, Yea-Tyng Fan, Hsueh-Min Lin
Landseed Hospital, Ping-Jen City, Taoyuan County, Taiwan
Objective
The project aimed to increase return rates for screening follow-up in women with abnormal Pap smears.
Background
Pap smear was the early detection method for cervical cancer, the most common cancer among Taiwanese women. The
follow-up rate for abnormal Pap test in our hospital was lower than the expected value set by government public health
center. The characteristics of most our target patients were older women with limited health literacy, and help taking care
of young grandchildren, a situation made them difficulty leaving home for a scheduled clinic appointment.
Methods
Pre and post measurement of follow-up rates was main outcome indicator in our project. 1,167 women who received Pap
smear screening in our hospital between October and December in 2009 were enrolled in the project. A Plan-Do-CheckAct cycle was applied. Baseline data collected by phone interview with women who were lack of follow-up for abnormal
Pap smears. Key factors of not return visits were identified after the cause-and-effect diagram created. Two main
interventions, (1) a personalized return visit appointment with continuous reminder phone calls until the follow-up was
done, (2) an individualized patient education in abnormal Pap smears consequences and the importance of appropriate
follow-up, were implemented to improve low follow-up visits.
Results
The follow-up rate of abnormal Pap smears was enhanced from 77% to 100% in 6 months after the 2 interventions were
combined utilized. The 2 interventions were then added into clinical standard operating procedure for abnormal Pap
smears case management guideline revision.
Conclusions
Early detection of cancer is as important as cancer prevention. By utilizing the Plan-Do-Check-Act cycle, they key factors
interfering with women’s follow-up behaviour were correctly identified. Therefore, the result in the project was better than
expected goal. In conclusion, Plan-Do-Check-Act cycle was an effective tool for a clinical setting to ensure patient care
quality.
0517
The project to improve nursing care chemothrapeutic guideline in pediatric cancer ward
Chia-Hui Tsai, Chiu-Ping Hou, Li-Ying Wan, Tzu-Ping Su
Chang Gung Medical Hospital, Kaohsiung,NIAO-SUNG, Taiwan
The aim of the project was to improve the nursing care quality in pediatric cancer ward. Before the project, completion
rate of the standard guidance for chemotherapy and cancer children care among the nursing staff was 60%. Moreover,
only 62% of the nursing staff had comprehensive knowledge of chemotherapy and cancer children care. The satisfaction
rate for the nursing staff’s performance among the parents was only 73.9%. The intervention through this project included
strengthening the nursing staff’s in-service education, utilization of " childhood cancer patients passport " for parents and
patients education and held group health education program for parents and the cancer patients twice a month. After the
project, the completion rate of the standard guidance for chemotherapy and cancer children care among the nursing staff
increased to 92%, and more than 98% of the nursing staff gained knowledge of chemotherapy and cancer children care.
Besides, the satisfaction rate for the nursing care quality among the parents increased to 95.1%. From our study, it
seemed that "childhood cancer patients passport " served as a good resource for both children patients for understanding
the diseases and how to care themselves. Also, "childhood cancer patients passport" provided a bridge between the
parents and nursing staff for the cancer children care. In conclusion, the establishment of comprehensive care guidance
according to standard procedures and enhancement of nursing staff’s in-service education provided a lot of advantages.
0519
Evaluation of an Australian National Clinical Handover Initiative Pilot Program: lessons and outcomes
Suellen Allen, Margaret Banks, Marilyn Cruickshank
Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia
Objective:
To evaluate the outcomes of the Australian National Clinical Handover Initiative Pilot Program aimed to improve handover
communication.
Methods:
In 2010, an External Evaluation of the Australian National Clinical Handover Initiative Pilot Program (the Pilot Program)
was commissioned. The Pilot Program was funded in 2007-2008 and included fourteen pilot projects across 53 sites in
the acute, private, primary and aged care sectors across Australia. The Pilot Program aimed to develop and trial practical
and transferrable solutions for improving handover communication.
The External Evaluation completed in 2010 evaluated outcomes of the following Pilot Program objectives:
•
significant, sustained and measurable reductions in communication gaps
•
reliable measures of impact on patient outcomes
•
national learning on handover across the continuum of care
•
standardised operating protocols for handover based on the best available evidence and designed to accelerate
systemic improvements.
The evaluation utilised qualitative research methods using a program logic approach and included:
•
a policy audit
•
assessment of barriers, enablers and key success factors for project implementation, outcomes, impacts,
sustainability and spread of the program.
Data collection included semi-structured interviews; group discussions; review of the Australian handover policy and
program evidence prior to, and since inception of, the Pilot Program; and targeted consultation with key stakeholders. The
data were analysed thematically.
Results:
The 14 Pilot projects enabled the testing and development of approaches to improving clinical handover, tools and
standard operating protocols. The Evaluation identified a number of characteristics and factors that acted as drivers and
barriers for successful implementation, sustainability and spread of handover improvement. Success factors were
associated with tailored approaches to improving clinical handover, specific change management strategies and
organisational support. The evaluation results showed that the Pilot Program has had a significant impact in terms of
raising the profile of clinical handover and has advanced national learning on handover across the continuum of care.
Conclusions:
The evaluation found that the Pilot Program has been successful in achieving a number of its objectives. The evaluation
found that the Pilot Program has made a significant contribution to the published body of literature surrounding clinical
handover. This large multisite Pilot Program has reinforced the need for effective approaches to change, spread and
sustainability surrounding handover; and has identified gaps in handover knowledge and practice. This presentation will
present the key findings and lessons from the evaluation which is of significance to health care organisations planning to
implement improved clinical handover communication.
0532
Trends in mortality for AMI, stroke and hip fracture patients admitted to Norwegian hospitals during 1997-2001
and 2005-2009. Preliminary results.
Katrine Damgaard, Doris Tove Kristoffersen, Tomislav Dimoski, Jon Helgeland
Norwegian Knowledge Centre for the Health Services, Oslo, Norway
Objective:
The objective was to study mortality following hospitalization for first time acute myocardial infarction (AMI), stroke and hip
fracture during two separate 5-years periods.
Methods:
Patient administrative data (PAS) from all Norwegian health trusts for discharged patients during 1997-2001 (complete
from all trusts) and 2005-2009 (complete for 19 out of 24 trusts) were collected as part of an ongoing project for
developing 30 days mortality as a quality indicator for Norwegian hospitals. PAS provided type of admission (acute or
elective), primary and secondary diagnoses, time of admission and time of discharge. All permanent residents in Norway
have a personal identification number which enabled linking PAS to the National Population Register; the latter providing
age, gender and date of death. PAS records for AMI, stroke and hip fracture at each hospital were identified according to
the International Classification of Diseases (ICD); ICD-09 from 1997 to 1999 and ICD-10 thereafter. Patients were
excluded if the admission was coded as dead on arrival, a non-acute case, readmission or admission for rehabilitation,
and if the patient was < 18 years for AMI and stroke, and < 65 years for hip fracture.
The in-hospital mortality within 30 days, in- and out-of-hospital mortality within 30 days and in-and-out-of-hospital mortality
within 1 year were based on patients. For patients transferred between hospitals we counted from the first day of
hospitalization in the chain of admissions. No risk adjustments were performed. Each mortality measure is calculated as
the proportion of deaths among all first time patient admission during each 5-years period.
Results:
The mortality during 2005-2009 was significantly lower for AMI and stroke patients as compared to 1997-2001. For hip
fracture the 30-days mortalities remained unchanged or increased slightly.
AMI
Stroke
Hip fracture
In-hospital mortality,
1997-2001
16.9%
14.5%
3.9%
within 30 days
2005-2009
10.4%
10.3%
4.2%
In- and-out-of hospitality
1997-2001
19.2%
17.5%
7.9%
within 30 days
2005-2009
13.3%
13.8%
8.1%
In- and-out-of hospital mortality
1997-2001
28.7%
29.7%
25.5%
within 1 year
2005-2009
23.1%
25.4%
25.5%
Conclusion:
The reduction in AMI and stroke mortality during 2005-2009 compared to 1997-2001 is not observed for hip fracture. It
remains to calculate the mortalities when including data from the remaining trusts for 2005-2009.
0533
How should patient transferrals be accounted for when calculating in- and-out-of-hospital mortality as a quality
indicator?
Doris Tove Kristoffersen, Katrine Damgaard, Jon Helgeland
Norwegian Knowledge Centre for the Health Services, Oslo, Norway
Objective:
The objective was to evaluate a weighting method (WM) based on all hospital stays for transferred patients when
calculating 30 days in- and-out-of-hospital mortality.
Methods:
We define 30 days mortality for hospitals to be the number of all-cause-deaths occurring in- or out-of-hospital within 30
days, counting from first day of admission, among all patients admitted. When using mortality as a quality indicator for
hospitals, a major challenge is to attribute the outcome (alive or dead) to each hospital for patients who are transferred
between hospitals. There is a lack of research evidence to guide this attribution. Consider a patient who stayed five days
in one hospital, was transferred and stayed for two days in a second hospital, was transferred to a third hospital in which
the patient died 10 days after admission. One approach is to include patients with a single hospital stay only (XM); i.e.
excluding all patients transferred to another hospital. We tentatively propose to use analysis weights proportional to the
length of stay in each hospital (WM). In our example, the patient was hospitalized for 5+2+10=17 days. By using weights
the contribution to the outcome (death) is 5/17 for hospital no. 1, 2/17 for hospital no. 2 and 10//17 for hospital no. 3. This
weighting provides mortality based on all admissions and all hospitals. The weighted outcomes add up to the total number
of patients. Alternatively, the weights may used in the model specification of a logistic regression.
To compare XM and WM, we used data from a Norwegian nationwide all-hospital sample. Patient administrative data
(PAS) from all Norwegian hospitals were collected for patients discharged during1997-2001 for first-time acute myocardial
infarction (AMI), stroke and hip fracture. PAS provided type of admission (acute or elective), primary and secondary
diagnoses, time of admission and time of discharge. This information was linked with the National Population Register,
which provided age, gender and date of death independent of place of death. All permanent residents in Norway have a
personal identification number (PIN) which enables linking between registers. This offers a unique opportunity to study
different ways of calculating mortality as we are able to identify patients across hospitals and official national registers.
A patient was defined as transferred if admitted to next hospital within 24 hours from time of discharge from a previous
hospital. 30 days hospital mortality was calculated by WM and by XM. Spearman rank correlation coefficient was
calculated to compare the hospital rank achieved by the two methods. Outliers were identified by
Results:
Totals of 48 030 (55 hospitals) AMI patients, 47 730 (59 hospitals) stroke patients, and 39 816 patients (58 hospitals)
were included. The proportions of patients admitted to more than one hospital were 5.1%, 4,8%, and 6,6% for AMI, stroke
and hip fracture, respectively. Both methods identified hospital outliers. The Spearman rank correlations were: AMI r =
0.88; stroke r = 0.80; hip fracture r = 0.67. However, outlier status differed between the methods.
Conclusion:
Assigning weights proportional to the length of stay at each hospital for transferred patients seems to be an appropriate
method for calculating hospital mortality as all admissions and all patients are utilized. The WM requires unique PIN.
0536
Determinants of quality of life in rheumatoid arthritis
Kaja Põlluste, Riina Kallikorm, Margus Lember
Department of Internal Medicine, University of Tartu, Tartu, Estonia
Objective:
The purpose of the study was to explain the determinants of quality of life (QoL) in Estonian adult patients with
rheumatoid arthritis (RA).
Methods:
Between October 2007 and January 2008, we conducted a postal survey amongst Estonian adult patients with RA. A
random sample (n=1259) of patients was selected from the Estonian Health Insurance Fund database. The patients
completed a self-administered questionnaire, which included information about their socio-demographic and disease
characteristics, self-reported use of healthcare, waiting time to and satisfaction with doctors, satisfaction with diseaserelated information obtained and sources of information. Patients’ QoL was measured with the 36-Item Short Form Health
Survey (SF-36). The impact of the variables on the each dimension of QoL was analysed with the linear regression
analysis.
Results:
The response rate was 63%. The average scores of the dimensions of QoL (mean±SE) were as follows: (1) physical
functioning (PF) – 49.1±0.8; (2) role physical (RP) – 30.0±1.2; (3) bodily pain (BP) – 39.6±0.7; (4) general health (GH) –
32.0±0.5; (5) vitality (VT) – 36.5±0.5; (6) social functioning (SF) – 55.5±0.8; (7) role emotional (RE) – 36.9±1.3; (8)
emotional well-being (EWB) – 56.2±0.6. The regression analysis resulted in models for the dimensions describing the
2
2
physical health including eight factors for PF (R =0.36), nine factors for RP and GH (R =0.36 and 0.24) and ten factors for
2
2
BP (R =0.30). The models of dimensions describing the mental health were explained by six factors for RE (R =0.20),
2
2
seven factors for VT and SF (R =0.17 and 0.22) and eight factors for EWB R =0.13).
Older age, co-morbidity and loss of income due to RA predicted lower scores of each dimensions of QoL, the higher
income, on the contrary was found to predict higher scores of all dimensions. Also, the self-reported higher number of
visits to the family doctor and rheumatologist predicted lower scores of most dimensions of QoL. Longer history of RA had
a negative effect on PF, RP, BP, GH and VT, bone fractures in adult age affected RP and GH. Better information about
the treatment scheme of RA had a positive effect on RE and VT. Satisfaction with the rheumatologist increased the
scores of EWB and SF and satisfaction with the information provided by the rheumatologist resulted in higher scores of
RE and VT. Longer waiting time to see the rheumatologist reduced the scores of GH and EWB; longer waiting time to the
GP also predicted lower score of EWB. Treatment compliance an use of complementary medicine were associated to the
lower scores of BP. Higher educational level of the patients had a positive effect only on the PF.
Conclusion:
QoL as measurable health outcome was affected by several socio-demographic and disease-related factors. On the other
side the worse QoL itself leads to increased demand of medical help. Therefore, the higher frequency of visits to the
doctors, better compliance and use of complementary medicine as predictors of lower scores of QoL was rather
expectable result. If the disease-related factors predicted the lower scores of physical health then the aspects related to
the access to the doctors, satisfaction with the doctors and information obtained contributed to the mental dimensions of
QoL. Thus, the physical health could be improved by the continuous and adequate medical surveillance while the better
access to the health services and good patient-doctor relationship might improve the mental aspects of QoL.
0540
Characteristics and Consequences of Falls, and Risk Factors for Injuries Due to Inpatient Falls for Selected
Hospitals in Taiwan
Yueh-Jiau Yang
University of Kang Ning, Tainan, Taiwan
Objective:
To discover potential risk factors for injury, serious injury and severity of injury due to inpatient falls.
Methods:
This prospective study examines fall incident data from eight acute care hospitals in Taiwan. Regression analyses of
these data were performed to discover potential risk factors for fall-related injuries and their severity.
Results:
A total 717 inpatient falls have been collected. The mean age for patients experiencing no injury falls was 58.9 years,
while patients experiencing injury falls had a mean age of 60.3 years. The injury rate for patients experiencing falls
resulting in serious injuries was 5.4%. Significant predictors for falls with injuries were identified as: being admitted to a
district hospital; being admitted to an Orthopedic nursing unit; being accompanied by family members or friends while
hospitalized; being subject to falls in hospital locations other than the nursing unit to which admitted; older patients; and
having a cancer diagnostic category. Significant predictors for serious injury among patients experiencing falls were
identified as: patients admitted to district hospitals; patients sitting in a wheelchair; and patients with a Neurology
diagnostic category. Significant predictors of more severe injuries (higher severity scores) to patients experiencing falls
were identified: those admitted to district hospitals; those admitted to nursing units other than Internal Medicine and
Surgical nursing units; patients falling in hospital locations other than those nursing units to which they were admitted; and
those patients who were accompanied by family members or friends during hospitalization. Patients with less serious
injuries (lower severity scores) were those admitted to regional hospitals and those experiencing falls from a seated
position.
Conclusions:
The predictors for injury, serious injury, and severity of injury due to fall were identified. It is hoped that the results of this
study may serve as the basis for improving patient safety by reducing fall incidences and fall injury severity.
Key words:
Fall, Inpatient, Fall-Related Injury, Serious Injury, Severity of Fall-Related Injury
0545
A study of Taiwan regional teaching hospital in-patients and the factors for the incidence of pressure ulcer
Mah Chun
Taipei Medical University-Shuang Ho Hospital,Nursing Department,No.291, Zhongzheng Rd., Zhonghe District,
Taipei,Taiwan, Taipei, Taiwan
Objective:
Pressure ulcer has a high incidence in a patient of disability or bedridden elder. The pressure ulcer does not only need a
huge amount of time and medical expense to treat, it is associated with a high incidence of complaints and led causes of
mortality. This study was carried out in a new two years old regional hospital has 745 acute beds in Taipei, Taiwan. The
purposes of this cross-sectional study were designed to: (1) understand the incidence of inpatient pressure ulcer in the
unit (2) recognize the related factors influencing inpatient pressure ulcer (3). Prevent pressure sore development for the
making of policy and for decisions concerning the equipping of a unit with materials for pressure ulcer care.
Methods:
A total of 117 pressure ulcer patients from January to December 2010 were reported by Adverse Event Reporting System
(It is an electronic adverse event reporting system for any events). Data were collected by using structured form including
characteristics of the Braden Scale and pressure ulcer record sheet. Analyze the pressure ulcer incidence rate and
factors.
Results:
The results showed a pressure ulcer incidence rate of 0.064% for all patients (medical wards, surgical wards, operating
room and ICUs). The pressure ulcer incidence rate of bedridden patients is the highest (84.6%). In terms of ≧ 65 years
old patients pressure ulcer is 61.5%.Most pressure sores are grade 1(28.2%) and grade 2(65.0%) and located on the
sacral area (53.8%). Correlation coefficient and t-test indicates the relationship between the risk factors and the grade of
the pressure sore. The risk factors include sensory perception, moisture level, activity mobility and nutrition friction.
Conclusions:
Results of this study are: the interface pressure between soft tissue and mattress is the main factor to cause the pressure
ulcer and the accuracy of position change may affect the rate of pressure sore. We expect this study to serve as a
reference in clinical practice for promotion of the quality of patient care and to prevent pressure sore development as well
as to promote optimal patient outcomes.
0546
Patients' and health care workers' evaluations of a patient safety advisory
Jean-Blaise Wasserfallen, David Schwappach
1
2
Lausanne University Hospital (CHUV), Lausanne, Switzerland, Swiss Patient Safety Foundation, Zürich, Switzerland
Objective:
To assess patients’ and health care workers’ (hcw) attitudes and experiences with a patient safety advisory, to investigate
determinants of staff support and predictors for patients' safety-related behaviors
Methods:
A patient safety advisory disseminated to patients at three Swiss hospitals. A cross-sectional survey of the patients who
received the advisory and hcw caring for these patients explored patients’ and hcw’s acceptance and experiences with
the advisory. Hcw support for the intervention and patients’ intentions to apply the recommendations were modelled using
regression analyses.
Results:
1053 patients and 275 hcw returned the questionnaire (participation rate 43% and 51% respectively). Patients (95%) and
hcw (78%) agreed that hospitals should educate patients how to prevent errors. Hcw and patients' evaluations of the
advisory were positive and followed a similar pattern. Patients’ intentions to engage in safety were predicted by behavioral
control (β=0.67, CI 0.59-0.75, p<0.001), subjective norms (β=0.28, CI 0.22-0.35, p<0.001), attitudes (β=0.12, CI 0.03-0.21,
p=0.009), safety behaviors during hospitalization (mean adoption scale score β=0.10, CI 0.04-0.16, p=0.002) and
experiences with taking action (β=0.18, CI 0.10-0.27, p<0.001). Hcw support for the campaign was predicted by rating of
the advisory (OR 3.4, CI 1.8-6.1, p<0.001), the belief that it prevents errors (OR 1.7, CI 1.2-2.5, p=0.007), perceived
increased vigilance of patients (OR 1.9, CI 1.1-3.3, p=0.034), and experience of unpleasant situations (OR 0.6, CI 0.4-1.0,
p=0.035).
Conclusion:
The advisory was well accepted by patients and hcw. To be successful the advisory should be accompanied by measures
that target norms and barriers in patients, and support staff in dealing with difficult situations.
0551
The quality assessment of total parenteral nutrition in the hospital
Mei-Lie Cheng, Chun-Chieh Yang, Chi-Lun Tsai
Chi Mei Medical Center, Tainan, Taiwan
OBJECTIVES:
To assess the compliance of quality control for the total parenteral nutrition (TPN) in the hospital.
METHODS:
This was a retrospective study using a medical record review of the adult hospitalized patients receiving TPN in one year
from July 1, 2009 to June 30, 2010 in a tertiary care center. In this institution, the Nutrition support team (NST) has
responsibility to minimize the complications and errors associated with TPN therapy. The NST was asked to review the
laboratory values and clinical course of these patients, evaluate and modify their therapy to maximize compliance with
guidelines. This study applied 16 nutrition quality criteria to the TPN assessment in the adult patients. The quality criteria
and their standard values yielded from the previous relevant literatures and the American Society for Parenteral and
Enteral Nutrition (ASPEN). The degree of compliance was assessed by the comparison of the standard values with the
clinical results.
RESULT:
A total of 138 adult patients (93 men; 45 women) received TPN were recruited during one year period in the hospital, from
July 1, 2009 to June 30, 2010 was analyzed. There were about 2437 hospital days; 17.6 therapy days averagely (range, 2
to 84 days); 66.7 years old averagely (range, 25-87 years old). The degree of compliance for quality criteria (standard
values vs. clinical results): obtaining the nutritional assessment within 24 hours after the request for TPN (100%
vs.89.9%), indication for TPN established by the ASPEN (100% vs.100%), time of fasting prior to starting TPN must be
less than 7 days (80% vs.84.8%), duration of TPN over 7 days (90% vs.93.5%), concordance of calorie requirement
(100% vs.100%), therapy within 24 hours of prescription (100% vs.100%), no mechanical complications (98% vs.100%),
no infectious complications (90% vs. 81.2%), no hepatic complications (95% vs.100%), no biliary complications (95%
vs.94.2%), no metabolic complications (90% vs.88.4%), no delay in administration (100% vs.100%), no errors in the
composition of TPN (100% vs.99.3%), no transitory interruption of the TPN (90% vs.94.2%), no return be greater than 2%
of the total of bags prepared(100% vs.99.3%), microbiological control results must be negative(100% vs.100%). There
were 10 clinical results within the standards, however, the remainders fell below the standard.
CONCLUSION:
Although most of the clinical results were within the standards, however, it is necessary to continue improve the quality
control especially for those clinical results below the standard. Nutrition support team should be aware of how TPN is
used to maximize guidelines compliance and patient outcomes.
0553
Identifying the practice challenges to improve services for children presenting with suspected physical abuse
and neglect.
Michelle Maiese, Shanti Raman, Katrina Hurley
Sydney & South Western Local Health Networks, Sydney, NSW, Australia
Objective:
To investigate the systems and process for the assessment of children presenting with suspected physical abuse and/or
neglect to hospital, for the purpose of identifying quality improvements.
Methods:
The project was a cross agency collaboration. Participants were from health and welfare organisations. There were 36
health professionals, doctors, nurses and social workers, from 10 acute hospitals in a metropolitan area. Additionally,
there were 18 child protection professionals from 11 local offices of the statutory child protection agency. Data collection
methods comprised 54 semi-structured interviews and 10 hospital site visits. Health services data, to estimate numbers of
children seen with suspected physical abuse and/or neglect, was also analysed. Document analysis of existing child
protection policy, procedures and protocols was undertaken.
Results:
Health respondents reported that an effective service was provided when the following conditions were met: assessments
were undertaken as a team; there was a culture of consultation with senior staff; good communication within and across
agencies existed; and, there were indentified referral pathways. Participants from the statutory child protection agency
reported a positive perception of the health assessments provided.
The practice gaps indentified were threefold, that is: inadequate awareness and recognition of physical abuse and neglect
among frontline health staff; variations in assessments undertaken; and, variation in use of procedures and protocols. Six
significant system problems were revealed: a lack of priority given to and no private waiting area for suspected child
abuse cases; different staffing arrangements across sites; ineffective data systems to capture child protection
presentations to health services; an inadequate follow up/tracking system for identified child protection cases;
unsatisfactory communication within and between agencies, including inadequate written reports; and, poor case
coordination across the health and statutory welfare agencies.
Conclusions:
The project identified the difference between the perception of providing an effective child protection health service and
the difficulty of doing so. The practice gaps and system problems have been recognised as issues to drive improvements
in the service provided. A twofold challenge exists: to improve service quality within the health system, and, to enhance
coordination across the health and welfare agencies. A significant step has been taken in identifying these areas for
improvement. A very vulnerable paediatric population is dependent upon them now being addressed.
0558
Service performance of General Ward Ventilator Team in Queen Elizabeth Hospital, Hong Kong
Wing Yiu Ng, Ruby Wong, Kam Wah Lam, Kin Wah Au Yeung
Queen Elizabeth Hospital, Kowloon, Hong Kong
Objective
To study if General Ward Ventilator Team (GWVT) can improve quality of care in patients receiving mechanical ventilation
in general ward.
Methods
Design: Case-control study
Setting: Queen Elizabeth Hospital is a 1,800 beds acute hospital and tertiary referral centre under Hospital Authority in
Hong Kong. While increasing number of patients required mechanical ventilation (MV), Ventilator Ward (VW) was
established in 2002 which provides 16 beds for patients requiring mechanical ventilation that cannot be admitted to
Intensive Care Unit (ICU)/ High-dependency Unit (HDU). Patients in the Ventilator Ward are cared collaboratively by their
original medical teams and a ward-based intensivist. Patients on MV in general wards before admitting to ICU/HDU or
Ventilator Ward are mainly cared by their own medical teams.
Intervention: In October 2010, General Ward Ventilator Team (GWVT) containing Intensivists and nurse specialists was
established and has started to provide advice on caring for patients receiving mechanical ventilation in general wards
regarding treatment strategy, ventilator setting, prognosis, Do-not-resuscitate (DNR) decision and end-of-life care plan.
st
st
st
st
Main outcome measure: Data of two periods, 1 October 2009 to 31 January 2010 and 1 October 2010 to 31 January
2011 are measured respectively and used for comparison. We collect data on ventilator days in general ward per patient
case, number of patients in general wards that received MV and cannot be admitted to ICU/HDU/VW within 24 hours;
Number of patients in general wards that receive MV and cannot ever be admitted to ICU/HDU/VW; and in-hospital allcause mortality of the patients that receive MV in general wards.
Results
st
st
From 1 October 2009 to 31 January 2010, 23,431 patients were admitted to general wards as emergency admission. Of
st
these, 2.5% of the patients ever received MV in general wards. Their mean age was 73.9 years. From 1 October 2010 to
st
31 January 2011, 23,330 patients were admitted to general wards as emergency admission. 2.2% of them ever received
MV in general wards. Their mean age was 72.2 years.
When comparing the two periods, the mean number of ventilator days per patient case in general ward dropped from 2.1
days to 1.8 days. The number of intubated cases that cannot be admitted to ICU/HDU/VW dropped from 108 cases
(18.2%) to 44 cases (8.8%) (P < 0.001). The number of intubated cases that cannot be admitted to ICU/HDU/WV within
24 hours also dropped from 180 cases (30.4%) to 90 cases (17.9%) (P < 0.001). The overall in-hospital all-cause
mortality of the ever mechanically ventilated patients in general wards dropped from 69.3% to 65.9%. However the
service cannot contribute to any statistical significant difference to patients that cannot be admitted to ICU/HDU/VW within
24 hours or patients that can never admit to ICU/HDU/VW.
Conclusions
The results suggest the GWVT led by intensivists and nurse specialists can lower the ventilator days in general wards,
increase the number of patients cared under appropriate units and improve the overall all-cause patient survival as
patients on MV in general wards can receive medical suggestion treatment from intensive care team when the critical care
facilities are saturated. However, the results suggest in future more intensive care beds are needed. Further researches
on cost-effectiveness of the GWVT, stakeholder satisfaction on the service provided by GWVT, appropriateness of
decision to provide mechanical ventilation and active resuscitation for the studied patients, functional outcome and quality
of life of the survivors are useful for future hospital management planning.
0559
Clinical outcomes evaluation using risk adjustment methodology: the example of Interventional cardiology.
Paulo Sousa, António Sousa Uva, Fausto Pinto, Florentino Serranheira
1
2
National School of Public Health, Lisbon, Portugal, CMDT, Associate Research Laboratory, Lisbon, Portugal
Objectives:
The aim of this study was to develop and test a risk adjustment model for major adverse cardiac and cerebrovascular
events (MACCE), following PCI procedures, using data from a national, multi-centre registry and to highlight the use of
the risk adjustment methodology when we evaluate the quality and safety of care in interventional cardiology.
Methods:
Retrospective analysis of 10.399 consecutives PCI procedures performed between June 30, 2003 and June 30, 2006 was
performed. Bivariate and multivariate logistic regression models were used to identify independent risk factors for MACCE.
Performance and calibration of the model was done, the area under the receiver operating characteristics (ROC) curve,
and the Hosmer-Lemeshow goodness of fit statistic, were calculated. After that the model was tested in the population
who has undergone PCI between July 2006 and June 2007. The ROC curve and the Hosmer-Lemeshow test were
calculated.
Results:
Factors associated with MACCE included, among others: age >80 (adjusted odds ratio (AOR) = 3.910); female gender
(AOR = 1.720); AMI (AOR = 2.682); cardiogenic shock (AOR = 6.048); renal failure (AOR = 2.981); ejection fraction
severely reduced (AOR = 3.940); three or more vessels treated (AOR = 2.175); and PCI urgent/emergent (AOR = 2.105).
The ROC curve and the Hosmer-Lemeshow goodness of fit statistic, for the multivariate prediction model, were 0.84 and
0.18, respectively, which indicate that this model has discrimination adequate for genuine clinical utility.
Conclusions:
A risk adjustment model for in-hospital MACCE after PCI, was successfully developed using a large national, multicenter
registry, with timely data analysis. The model was tested in a “real world” population, showing that it has discriminative
power adequate for genuine clinical utility. This represents a step forward on credible and reliable comparison of results
among providers, making it more meaningful. These findings will likely represent an important contribution to improve
quality and safety of care and should help driving new research and innovative approaches to different sub groups of
patients who have higher chances of having an adverse event or poorer outcomes following PCI.
0563
The effectiveness of streamlining elective surgery care in the public sector: the Alfred experience
1
1
2
2
Judy Lowthian , Andrea Curtis , Bernadette Comitti , Andrew Stripp
1
2
Dept Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia, Alfred Health, Melbourne, Australia
Objective: To evaluate the effectiveness of the clinical process re-design of peri-operative programs undertaken at the
Alfred Hospital in February 2007.
Methods: A before-and-after evaluation was conducted in late 2010, using de-identified administrative data for elective
surgery patients admitted to the Alfred Hospital between February 2005 and February 2010.
The Alfred is major tertiary hospital of 638 beds based in Melbourne, a state capital in south-eastern Australia, with a
population of 3.9 million in 2008.
With persisting growth in demand, by the end of 2005, the essential prioritisation of time-critical emergency surgical cases
had increasingly impacted on elective surgery, with hospital-initiated-postponements (HIPs) reaching almost 30% and
contributing to unacceptable delays in treating elective surgery waiting list patients.
In response to this situation, the Alfred set out in 2006 to streamline their peri-operative program using clinical process
redesign methods and co-location to a new dedicated elective surgery facility.
The primary aims were to improve the timeliness of patient care in the context of increasing demand for elective surgery
services.
Main outcome measures included the numbers of patients waiting beyond national recommended waiting times for
elective surgery, hospital initiated postponement (HIP) rates and diagnostic related group (DRG) specific and combined
lengths of stay (LOS). Analyses of changes in LOS were performed with Stata 11 using the Wilcoxon rank-sum test for
non-parametric data.
Results: The redesigned peri-operative services were centred on a stream-lined, standardised protocol led care pathway,
with a focus on the complete patient journey from initial referral to discharge. The re-design included construction of a
separate dedicated elective surgery facility which provided additional short-stay beds.
Following implementation of the re-designed processes, there was a 45% reduction in the numbers of patients waiting
beyond national recommended waiting times for elective surgery.
HIPs were reduced from 30% in 2005 to 1% in 2010 in the dedicated elective surgery facility.
In addition there was a reduction in the combined overall LOS for both the Alfred main hospital and Alfred Centre patients
from a mean of 4.8 days pre-redesign to a mean of 2.3 days post-redesign, as well as in specific LOS for several common
surgical procedures. The differences were statistically significant (p<0.000).
The overall percentage of patients discharged on the same day as their surgical procedure has increased since
implementation of the process redesign.
Informal surveys of Alfred Centre medical, surgical and nursing staff have shown an improvement in morale since the
introduction of the new model of care, and telephone follow-up of short stay planned surgery patients since September
2008 has indicated 100% satisfaction with the new preadmission process.
The strength of this study is the comparison of outcomes before and after the introduction of a redesigned model of care
in a major metropolitan teaching hospital. To our knowledge this is the largest study that has compared LOS before and
after implementation of a redesigned model of care.
Conclusions: The clinical process redesign with co-location of a dedicated elective surgery centre at the Alfred has
proved to be effective. Development of a streamlined patient-centred care pathway has been shown to improve the
timeliness of care for both elective and emergency patients; with reduced LOS, shorter waiting times and decreased
hospital-initiated cancellations for planned admissions. These efficiencies have had the additional benefit of contributing
to increasing the volume of surgery cost-effectively, thereby enabling the Alfred to meet its community’s rising demand for
acute care. These changes have improved patient flow, decreasing the potential to compromise patient safety at times of
clinical need, in the context of rising demand for services.
0565
The Investigation into Diminishing the Incidence of Incontinence Associated Dermatitis in Medical Intensive Care
Unit
WAN JEN LIU
Chang Gung Medical Center, Taoyuan, Taiwan
Skin integrity of patients represent quality of nursing care. However, the incidence of incontinence-associated dermatitis in
nursing unit was 54.3%. Factors associated with the dermatitis included skills of the nursing staffs and the cognition of
looking after being 50.4% and 75.5%,respectively.addition,incontinence dermatitis monitors and rules of looking after
were deficient the staff regarded it as press sore care. Etablishing special case group may decrease the incidence of
incontinence dermatitis. By the way of (1) establishing flow charts of new patients skin care,(2)creating the incontinence
dermatitis severity appraisal meter, (3)setting the rules of looking after incontinence dermatitis,nursing skill could be
improved by 41.9%,being 92.3% coherent the cognition was improved by 19.8%,being 95.3%.The incidence of
incontinence associated dermatitis reduces to be 15.5%. We expected that the special case of formulating the
incontinence dermatitis severity appraisal meter and the rules of looking after to be able to improve the looking after
quality of for skin of patients.
0566
Did the mortality rate reduced in patients with unexpected deterioration? Analysis from adverse-event reports.
1
2
2
2
Kazumasa Ehara , Maho Murata , Nobuya Kusunoki , Takahisa Kawashima
1
2
Graduate School of Health Care Sciences, Jikei Institute, Osaka, Japan, Kobe University Hosoital, Kobe, Japan
Objective:
Code-blue system became very popular in many hospitals. However, mortality rate of inpatient after CPA (cardiopulmonary arrest) is still high. However, there were some evidences to improve mortality rate of in-patients if we predict
start proper treatment earlier before the patients’ condition become serious such as the rapid response systems. We
have established adverse events reporting system since 2004. Fifty four adverse events due to unexpected deterioration
of vital signs were reported and reviewed by the department of patient safety and quality management in our hospital.
Methods:
Since 2004, we have established adverse events reporting system with fixed criteria and verified in the department of
patient safety and quality management in the university hospital (920 beds).
According to these evaluated adverse event reports, we compared the mortality rate between the early stage (group A,
2004 -2006. and the late stage (group B, 2007 - 2009). Among these 226 evaluated reports, 57 case were reported
because of rapid unexpected deterioration of vital signs including CPA.. Three cases were found in the out-patient-clinic
including the emergency unit. In other 54 cases of inpatients, deterioration found in ICU (10 cases), wards (29 cases), OR
(5 cases), Lab or Radiology (7 cases).
Results:
Between 2004 and 2006, various interventions were started in our hospital such as education of basic and advanced life
support, PHS code-blue system, DVT pulmonary embolism prevention program, distribution of AED, shock protocol etc.
The mortality rate of these inpatients' was compared between the early stage (group A, 2004 -2006. and the late stage
(group B, 2007 - 2009).
Over-all mortality rate was 41% (22 death /54cases) in patients with acute deterioration of vital signs, instead of 15% (35
death /226 cases) of total adverse event reports.
Among these 54 cases, cause of deterioration were respiratory systems in 19 cases circulatory systems in 12, central
nervous systems in 8 cases, cancers in 5 cases, anaphylactic shock in 4 cases, others in 4 cases, and unknown in 2
cases. The main causes of 19 respiratory systems were pulmonary embolism, a tracheal tube trouble, pneumonia, airway
obstruction, etc. In the circulatory system, they were heart failure, fatal arrhythmia, and artery dissociation, myocardial
infarction, etc.
There was no statistical difference in mortality rate between group A (36%) and group B (38%). There were also no
difference in mortality rate due to cardiac problem between group A and B. However, mortality rate caused by the
respiratory problem was decreased significantly from 50 % in group A to 27 in group B. Moreover, in the case of the
causes of a central nervous system (i. e. cerebral infarction etc.), although mortality rate was low and all patient was
recovered from the anaphylactic shock throughout these periods. Even though establishment of PHS based code-blue
system, mortality rate after CPA was still high (92%).
Conclusions:
According to these data from advance event reports, we found some improvement in mortality rate of patients with
unexpected deterioration of vital-signs caused by the respiratory problem. Our data suggested the possibility of
improvement of mortality rate if we treat for these patients with more systematic approach earlier before cardio-pulmonary
arrest
0567
Prioritizing quality indicators for colorectal cancer care
1
2
3
4
Fumiaki Nakamura , Takahiro Higashi , Kenichi Sugihara , Tomotaka Sobue
1
Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health,
2
3
Kyoto, Japan, Department of Public Health, University of Tokyo, Tokyo, Japan, Tokyo Medical and Dental University,
4
Tokyo, Japan, National Cancer Center, Tokyo, Japan
Objective: To prioritize previously developed process-of-care quality indicators for colorectal cancer in order to establish
a feasible quality measurement system.
Methods: Process-of-care quality indicators were prioritized according to four major factors: impact on outcome, room for
improvement in performance, validity of measured scores, and number of eligible patients. A multidisciplinary panel of 13
experts, including gastrointestinal surgeons, endoscopists, and medical oncologists, assessed each quality indicator
based on the four major factors and then prioritized the quality indicators on a scale of 1 to 5 (1, lowest; 5, highest). The
panel rated each quality indicator prior to a group discussion. After assessing the distribution of first ratings, they
discussed the priority as well as the revision of the indicators. The panel then rated each quality indicator a second time.
During the rating process, performance data for 1,506 patients among 16 community cancer center hospitals were
considered. The panel was asked not only to consider how each quality indicator performed according to the four major
factors, but also to assign an overall priority for each quality indicator. Overall priority of each quality indicator was
determined based on the average priority ratings among the panel. To confirm the validity of the overall priority ratings, we
also examined the correlation between overall priority score and four major factors.
Results: The 10 highest priority quality indicators were as follows: three indicators for diagnosis (enhanced abdominal
computed tomography before surgery, documentation of endoscopic findings before surgery, and pelvic imaging tests
before surgery for rectal cancer patients), two indicators for surgical therapy (wide lymph node dissection with central
vascular ligation for Stage 2/3 colon cancer patients and documentation of pathological findings after surgery), one
indicator for endoscopic treatment (documentation of endoscopic and pathological findings), one indicator for
chemotherapy (adjuvant chemotherapy for stage III colorectal cancer patient within 8 weeks after surgery), and three
indicators for follow-up (enhanced abdominal computed tomography every six months after surgery for five years, imaging
tests every four months for patients receiving chemotherapy, and total colonoscopy within six months after surgery for
patients without total colonoscopy prior to surgery). The “impact on outcome” factor had the strongest influence on the
overall priority ratings (r=0.78). In general, quality indicators that focused on the appropriateness of information disclosure
were given a relatively low overall score. Additionally, the panel proposed modification to eight indicators, including two
that were listed in the 10 highest priority quality indicators.
Conclusions: Colorectal cancer quality indicators were successfully prioritized in this study. A quality measurement
system including the 10 highest priority quality indicators can help establish a simple and useful quality measurement
system for colorectal cancer care.
0570
The Development and Validation of a Scale to Measure Clinical Preceptor’s Teaching Performance
1
1
2
1
Wan-Ching Chao , Hwa-Nien Liu , Ju-Chun Chien , Mei-Hua Sun
1
2
Far Eastern Memorial Hospital, New Taipei City, Taiwan, Oriental Institute of Technology, New Taipei City, Taiwan
Objective:
The purpose of this study was to develop a Chinese version of the Clinical Preceptor Teaching Performance Scale
(CPTPC) and evaluate its validity and reliability.
Methods:
After reviewing the literature, the original items of the CPTPC were generated by means of taking a semi-structured
interview with 10 outstanding preceptors for an in-depth understanding of their own experiences as preceptors.
The 28 generated statements were categorized into four aspects: preceptor’s nursing expertise, preceptor’s teaching
attitudes, preceptor’s instructional skills, and preceptor’s role modelling. Five experts in the content area reviewed and
modified the items, which resulted in a smaller pool of 25 items.
A seven-point rating scale was used in the CPTPC. The scale of answer was from 1 (very different) to 7 (very alike); a
higher score indicated a better teaching performance in nursing.
After a pilot study, the scale was administered to a sample of 333 registered nurses on 24 units of a medical centre in
Taiwan in June, 2010. The test-retest reliability of the CPTPC was gathered in December, 2010 (n = 134).
The data were analyzed using descriptive statistics, item analysis, exploratory factor analysis, internal consistency
reliability, test-retest reliability, etc.
Results:
The results of item analysis indicated that the 25 items of the scale were highly correlated with one another; thus, it’s not
necessary to delete items from the scale. The 25 items were then factor analyzed by using principal components analysis
and Promax rotation.
The KMO value was .97 and the communalities for each item were greater than .5. Twenty-five items were grouped into
4 factors, including Preceptor’s Nursing Expertise (5 items), Preceptor’s Teaching Attitudes (9 items), Preceptor’s
Instructional Skills (5 items), and Preceptor’s Role Modelling (6 items). The percentage of variance in preceptor’s
teaching performance explained by the 25 items of the CPTPC was 81.42%. The internal consistency of the CPTPC for
an overall coefficient alpha was .98 and the values of coefficient alpha for the four subscales ranged from .91 to .96. The
test-retest reliability for the total scale after 6 months was .60. The test-retest reliability coefficients for the four subscales
ranged from .47 to .57.
Conclusions:
Preceptoring is a valuable strategy in promoting quality and safety competency development in nursing for newly hired
nurses. However, few validated instruments for assessing preceptor’s teaching performance are currently available in
Taiwan. This study has developed a Chinese version of the Clinical Preceptor Teaching Performance Scale and has
demonstrated acceptable reliability and validity estimates. The CPTPC would be a useful tool for conducting preceptor
development programs.
0571
A comprehensive rehabilitation program in partnership with community resources to improve the outcome of
patients with Congestive Heart Failure
Yiu Fai Terence Lee, Sim Heung Yeung, Man Chun Choi, Shu Kin Li
Pamela Youde Nethersole Eastern Hospital, Hong Kong
Objective: To reduce hospital readmissions, length of stay and improve CHF patients’ quality of life through a
comprehensive rehabilitation program.
Methods: A team of Cardiologist, Ambulatory Care Physician and Cardiac Nurse in Pamela Youde Nethersole Eastern
Hospital was established to identify, assess, intervene and monitor selected patients admitted with CHF, from in-patient
assessment to pre-discharge education and counseling, and post-discharge management including telephone follow-up
and enquiry service, early clinic follow-up and physical/psychosocial rehabilitation. Information material were developed
on heart failure medications in the form of color flash cards show commonly used medications to assist patients in
identifying medications and dosages, educational booklet, a heart failure video and a take-home information sheet.
Inclusion criteria: age > 20 – 100 years with a primary or secondary diagnosis of heart failure. Exclusive criteria: history of
dementia, mental illness, end-staged renal failure or terminal illness. Outcomes of patients with intervention and control
group into program were analyzed: readmission at 60-day, duration of hospital stay (LOS) due to CHF and patient
satisfaction with the program.
Results: A total of 921 patients were recruited from July 2009 to December 2010. Their mean age was 75.8 yrs, with 50%
of them having history of recurrent admission for CHF. A total of 1370 phone follow-up and 291 phone enquiry services
were provided, in which 95 episodes of early of CHF and potential for hospital readmission were identified but settled with
drug titration and education.136 patients received cardiac rehabilitation and 134 attended psychosocial workshop at the
Patient Resource and Community Centre.
Control Group
Intervention Group
Numbers of patients
819
921
60 day readmission due
to CHF
320 cases, ~39%
186 cases, ~20%
1437 days
647 days
4.5 days per patient
3.5 days per patient
Before program
After program
60 day readmission due
to CHF
218 cases
123 cases
Total LOS during
readmissions in 60 days
1365 days
383 days
6.3 days per patient
3.1 days per patient
Total LOS during
readmissions in 60 days
Reduction
42%
55%
Patients with recurrent
history of CHF
Reduction
(458 out of 921
intervened patients)
44%
72%
Patients’ satisfaction survey was conducted with satisfactory results.
Conclusions: Through collaboration between hospital multidisciplinary team and partnership with community resources,
provision of heart failure clinic, home visit and phone management program, patients with CHF can be engaged and
manage their illness through a self-care educational program that focus on their perceptions, experiences and beliefs to
take care of their clinical, psychosocial and rehabilitation needs, improving their quality of life and preventing hospital
readmission.
0572
Evaluation of the Association of Total Parenteral Nutrition Related Infection
Hwung-Chung Lee, Wen-Ching Wang
Chi-Mei Medical Center, Tainan, Taiwan
Objective:
Patients who receive total parenteral nutrition (TPN) by central venous catheter (CVC) would easily get catheter-related
blood-stream infection, which may lead to prolonging hospital stay, increasing medical cost and mortality rate. Therefore,
by looking into the related factors of getting infection, we can decrease the odds of being infected. The aim of the
research is to describe the infection rate, the association between infection and patient characteristic, and the association
of infection rate and the patients’ nutrition condition.
Methods:
This is a retrospective study in a medical center in southern Taiwan, using data from patients in ordinary ward from
st
st
January 1 , 2007 to December 31 , 2009. We only included patients who were more than twenty years old and received
TPN longer than seven days. Using the chart record of TPN infection via CVC as the study tool, the researcher started
with checking the medical charts, which included the variables such as age, gender, skin condition, underlying disease,
days of use of TPN, usage of steroid, blood sugar level, nutrition indicators and so on. Followed by using SPSS 17.0
software for further analysis, the related factors were analyzed by Chi-square test, Fisher’s exact test and Student’s test.
Results:
There were 681 patients who received TPN but only 145 patients were qualified to the research. Among them, 31 patients
were found to have TPN-related infection (the infection rate: 21.4%). The mean age of the patients were 64.3 ± 14.3 years
old (range: 29~88 years old) and there were 94 males (64.8%) and 51 females (35.2%). The mean length using TPN is
21.5 ± 14.6 days (range: 8~80 days). The average level of albumin is 2.7 ± 0.6 mg/dL (range: 1.4~4.2 mg/dL) and prealbumin is 14.8 ± 5.3 mg/dL (range: 3.0~28.0 mg/dL). With further analysis, it was found that the TPN-related infection
was significantly correlated with factors such as gender, duration of TPN administration and mean albumin level. The
research showed that male patients had less infection rate than the female patients (male: 16% / female: 31.4%) ;
patients who received longer TPN administration tended to have more risk than those who got shorter ones (infected:
31.23 ± 19.82 days / uninfected: 18.81 ± 11.57 days) ; the mean albumin level of patients who got infection was lower
than those who didn’t (infected: 2.49 ± 0.63 mg/dL / uninfected: 2.74 ± 0.59 mg/dL). As to other variables, there was no
significant difference.
Conclusions:
There was higher TPN-associated infection rate in patients who were female, received longer use of TPN , and lower
mean albumin level. So we suggested that the TPN-associated infection rate can be redused by shorter interval using
TPN, earlier enteral nutrition, and improving the nutrition status of the patients.
0574
Consumer participation – from passive to partnership
JOYCE MURPHY, ELIZABETH HARNETT
THE CHILDREN'S HOSPITAL AT WESTMEAD, SYDNEY, NSW, Australia
At The Children's Hospital at Westmead, we rely on consumers to make sure we get our services and facilities right.
Anything we can do to encourage the involvement of families in quality and safety improvements in the Hospital means
that ultimately, we’re going to do things better for the children and young people we care for.
Consumer participation can reap great rewards for both consumers and health care providers. The consumer participation
spectrum starts with ‘inform’ and as consumer input rises at each level of the spectrum, decision-making is increasingly
shared between staff and consumers.
The Children's Hospital at Westmead’s multi-faceted Consumer Participation & Partnerships Program enables staff and
consumers to engage in consumer participation strategies at all levels of the spectrum. The program offers resources,
training and support to both staff and consumers, to make consumer participation effective and successful.
While there is a lot of consumer participation activity, much of it happens at the left end of the spectrum – inform and
consult – where staff traditionally feel comfortable operating. But as the program continues to gain momentum, and with
increasing support and resources, the pendulum has started to swing the other way, to greater partnerships and
collaboration.
This presentation describes the various elements of our consumer participation and partnerships program, strategies to
increase partnerships with consumers and how bringing together staff and consumers needs to happen in many ways: on
paper, face-to-face and on line. We’ll also share some of the excellent results we’ve achieved when working in
partnership with consumers.
0577
The improvement project of artificial reproductive medicine injection procedure
Liu Hsiao-Yun, Cheng Heng-Feng, Zhang Min-Yu, Chen Lih-Chin
CHANG Gung Memorial Hospital, Taoyuan, Taiwan
Objective:
Because of the social structural changes, the prevalence of infertile couples have risen. Nearly 10~15 couples are
diagnosed of infertility in every 100 pairs, who require artificial reproductive technology for treatment. However, careless
mistakes during the treatment procedure may occur along the course, which not only can do harm to the patient, but also
may damage the reputation of nursing staffs and the hospital. The current investigations of artificial reproductive medical
procedures have revealed its incompleteness, which caused incorrect drug injection incidence; therefore, improvements
on three aspects: system, procedure, and personnel, are expected to avoid incorrect drug injections, which guarantee
patient safety.
Method:
To propose a solution via current investigation and literature review
First, to set up information-based drug advice system, which enables doctor to key-in the correct prescription Second, to
establish routine procedures during duty transferring regarding to prescribed medication: Distinguish procedures between
weekdays and holidays (including night shifts). Set up duty transferring system between units and promote amongst
associated staffs. Third, to hold a training program related to 'introduction to artificial reproductive medicine', to improve
nursing staffs' knowledge of drug recognition. Fourth, to set up inter-department cooperation with the pharmacy
department for timely updates of artificial reproductive drug information WebPages, which offer inquiry for the medical
team.
Result:
Under the routine use of computerized doctor's order system, the incidence of incorrect medication decreased from 3% to
0%; Duty transferring procedures allow nursing staffs to have in hand of the injecting drug information for each patient.;
The drug introduction training program improved the recognition of drugs by nursing staffs from 81.5 to 97.9 points; The
timely updates of drug information webpage allowed personnel in grasp of the latest drug information at any time, which
decreased the incorrect injection rate of artificial reproductive drugs from 8% to 0% and promoted nursing quality and
patient safety.
Conclusion:
This project consisted of making computerized drug advice system for artificial reproduction, holding training programs for
duty transferring procedures, and update for drug information WebPages, to achieve safety drug injection for artificial
reproduction, high-quality treatment for the patient, and increase the sense of achievement of nursing staffs.
0580
From Anxiety to Confidence – Engaging and Enhancing Confidence of Nurses in Preparing Queen Mary Hospital,
Hong Kong for Accreditation
Kate Choi
Queen Mary Hospital, Hong Kong
Objective
To accomplish the critical task of engaging more than 1500 nurses and enhancing their confidence in preparing and
supporting Queen Mary Hospital (QMH) for accreditation survey by the Australian Council on Healthcare Standards
(ACHS) in October 2010.
Introduction
Hospital Accreditation is new to public hospitals in Hong Kong. After announcing in 2009 that QMH would be one of the
five pilot sites for Hospital Accreditation, all nursing staff were very anxious as they did not know the “What”, “Why” and
“How” to prepare for ACHS Organization Wide Survey (OWS). Engaging more than 1500 nurses and enhancing their
confidence in accreditation was therefore a critical task for the QMH nursing management.
Methods
Continuous Quality Improvement (CQI) method was adopted to engage all nursing staff; enhance their understanding of
ACHS accreditation standards and process; allay their anxiety and enhance their confidence in undertaking improvement
projects and preparing QMH for accreditation survey. This was achieved by bringing updated information to nursing staff,
continuing staff education, assuring nursing practices, monitoring compliance with ACHS standards, identifying services
gaps, implementing improvement projects and evaluating outcome of interventions.
Results
1)
Changes in Staff’s Attitudes: from Anxiety to Confidence
By launching various staff education and engagement programmes, it was evident that nursing staff’s attitude
towards accreditation survey has changed appreciably over time. Before, they were sceptical and anxious because
of lack of knowledge and understanding of accreditation survey. They also criticized that the accreditation survey
would pose additional workload and was time consuming, burdensome and repetitive. However, with on-going staff
education, QMH nurses were well prepared for and were confident in participation in the accreditation process.
2)
Improvements in Nursing Service
In the run-up to OWS, opportunities for improvement related to nursing were identified in the gap analysis performed
by ACHS consultants. By adopting CQI methods, the nursing management, with full engagement and support of all
nursing staff, was able to successfully bridge the identified gaps and bring about significant improvements, such as in
establishing overarching disinfection/sterilization policy; reinforcing the concept of ‘clean and dirty segregation’;
implementing instrument tracking system; launching Nursing Care Plan and Patient Discharge Care Plan; enhancing
nursing staff’s knowledge in handling of complaints; completing ward stock streamlining exercise; and eliminating
excessive stocking of wheel chairs, stretchers, trolleys and drip stands in wards. The success of these improvement
projects had also contributed to enhancing the confidence and conviction of all nursing staff in the preparation of
QMH for hospital accreditation.
Conclusion
All nurses in QMH were engaged and were working towards the common goal of achieving best results in hospital
accreditation. The most valuable outcome of the staff education and engagement initiative is that positive changes in staff
attitude happened and implementation of CQI projects ongoing with full confidence and commitment of all nursing staff in
QMH.
0584
Improvement of Health Care Standard through the ‘Incidence Occurrence Report’
1
3
3
1
Pongtorn Kietdumrongwong , Suwanna Ruangkanchanasetr , Ampaiwan Chuansumrit , Chaiwat Jinawong
1
2
Queen Sirikit Medical Center, Bangkok, Thailand, Cardiovascular and Metabolic Center, Bangkok, Thailand,
Department of Pediatric,Faculty of Medicine, Mahidol University, Bangkok, Thailand
3
Objective: To improve quality of care and also staff competency by implementing computerized Incident Report
programme.
Methods: A computerized program of ‘Incidence Occurrence Report (IOR)’ is created by using C#.Net. It is consisted of
five parts: first, identification of the person recording the IOR; second, the affected patient or the place where the event
occurs; third, the category of adverse events involving medication, intravenous fluid and blood component; anesthesia,
surgery and invasive procedure; communication; evaluation and diagnosis; patient care; and environment and safety;
fourth, the detail and severity of event designated as A to H, and the initial response of the medical personnel; fifth, the
correspondence of the risk management committee. The report once was created, sent to responsible persons
accordingly either via intranet mail or short message service (SMS). In cases of mild degree (A, B, C) which has not
reached the patient yet, the head nurse or in-charge nurse will approve the IOR within 24 hours, followed by the risk
manager and the risk management committee in 24 and 12 hours, respectively. In cases of moderate degree (D, E, F)
which has already affected the patients requiring closed observation, intervention or hospitalization, both the risk manger
and risk management committee have to approved the IOR within 12 hours. And finally, in severe degree (G, H, I) ranging
from harmful situation, life threatening and death, the risk manager and risk management committee will be informed
immediately by an automatic SMS through the personal telephone. The IOR will be presented to the staff in the monthly
meeting using graphic presentation that automatically prepared. Also, the computerized program will be automatically
printed out the monthly and yearly report. Competency of healthcare provider if linked to incidence will be evaluated.
Results: The implementation of this computerized IOR program starts through the education for the medical personnel
involving in the hospital service. The reporting system results in appropriated and immediate response of administrative
personnel to the ongoing IOR. The rate of report increased from 24 cases in January 2010 to 65 cases in December 2010.
The responsible personnel will perform the root cause analysis in order to maintain the proper health care standard. Top
management team has managed sentinel events and complains more effectively in timely manner.
Conclusion: A computerized program ‘Incidence Occurrence Report’ is effectively implemented through the routine
hospital service. It is a friendly program, easy to understand and implement, and less time consume.
0588
Applying HFMEA to Increase the Patient Safety of Chemotherapy: A Teaching Hospital's Experience in Taiwan
Hua-Sin Chen, Chung-Bin Huang, Victor C Kok, Su-Jane Yu
Kuang Tien General Hospital, Taichung County/Shalu Township, Taiwan
Objective
Applying healthcare failure mode and effect analysis (HFMEA) to increase the patient safety of chemotherapy.
Methods
HFMEA had been designed by the VA National Center for Patient Safety specifically for healthcare. During this period
from April to December 2010, this study was used a five-step process of HFMEA technique to identify potential
1
chemotherapy process failures in our hospital. Step 1: Define the HFMEA topic - applying HFMEA to increase the patient
safety of chemotherapy. Step 2: Assemble a multidisciplinary team - to integrate the various pre-existing professional
teams into one consisting of oncologist, chemotherapy nurse, chemotherapy pharmacist, information technology engineer,
and cancer center administrator. Step 3: Graphically describe the chemotherapy processes. Step 4: Conduct a hazard
analysis - hazard scores (HS) were generated from the probability of occurrence (1-4) and the severity of the potential
effect for the patient (1-4) of every failure mode. Step 5: Actions and outcome measures - Each potentially hazardous
failure mode was placed the decision tree to identify those demanded the immediate improvement actions and outcomes.
Results
In this study, we applied HFMEA technique to produce 91 and 153 failure modes and potential causes, respectively.
Above them, 7 medium probability failure modes (HS≥8) were identified by decision tree analysis, including: incorrect
prescription dosage (HS=8), unchecked prescription process (HS=9), incorrect dispension dosage (HS=8), incorrect
dilutention dosage (HS=9), patient error (HS=8), medication error (HS=8), and medication delivery problem (HS=8). After
HFMEA study period, the re-evaluation and specification for the chemotherapy processes were enforced in our hospital.
The computerized physician order entry was headlined the functions including dosage calculation automation and double
check the previous medication prescription. Besides, the chemotherapy pharmacist could check chemotherapy treatment
protocol in computer. And the prescription information was automated printing on bar-code label. Finally, the
chemotherapy nurse used the bar-code technique to recognize the chemotherapy patient and medications. During the
period of our intervention (from September 1, 2010, through December 31, 2010), the medication error events were
significantly descending. The percentage of the prescription error and dispension error were 0.0102% (14 events) and
0.0007% (1 events), respectively. And the HS of previous 7 probability failure modes had gone down (HS≤6). They were
incorrect prescription dosage (HS=4), unchecked prescription process (HS=3), incorrect dispension dosage (HS=4),
incorrect dilutention dosage (HS=6), patient error (HS=4), medication error (HS=4), and medication delivery problem
(HS=4), respectively.
Conclusions
In our teaching hospital which had 1,000 newly-appeared cancer patients annually. To increase the patient safety of
chemotherapy, we set higher goals for chemotherapy safety and applied HFMEA technique (a five-step process) to
improve chemotherapy processes. Our study was shown that HFMEA technique could effectively improve the
chemotherapy processs and could significantly increase the patient safety.
References
1.DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv 2002; 28(5): 248–67, 209.
0589
Reducing unplanned-extubation rate in neurosurgery intensive care unit
HSIN-CHIN LU, TSUN-MEI CHIU, YU-YI KAO
Chang-Gung Memorial Hospital, Taoyuan, Taiwan
Introduction and Purpose
Endotracheal tube intubation is a placement of a tube into trachea in order to maintain respiratory function in patients who
are unconscious or unable to breathe on their own, Moreover, for neurosurgical patients, hyperventilation and sedation
therapy by endotracheal tube is a essential strategies to reduce intracranial pressure. Unplanned extubation will result in
not only laryngeal edema, respiratory tract trauma but also secondary brain damage in neurosurgical patient. The aim of
this study is that reduce the unplanned endotracheal extubation rate by modify the care procedure and enhance nurses’
cognition. Thus, it could avoid endangering the patient safety and improve the perfect quality of care.
Materials and Method
It had been reviewed that the unplanned extubation rate was up to 0.43% of neurosurgical intensive care unit from
January to December in 2009. Hence, we collected information by reviewing documentations, on-site observations and
using checklist for inegrity. After analysis and discussion, four issues were proposed: (1) improper care of endotracheal
tube; (2) the lack of specific high risk assessment tool of self-extubation; (3) the lack of clinical guidelines for sedative
drug use; (4) inadequate physical restraint.
After discussion and analysis, the high-risk assessment of self-extubation was established for screening high-risk
neurosurgery patients. And prevention method was applied in the clinical setting immediately; The standards of sedative
drug use was also be set up to reduce discomfort of intubation patient. We designed a mnemonic to endotracheal tube
care for facilitating the integrity and correction of nursing care process. For the sake of proper physical restrain, we
additionally set uo a glove-type restraint bandfor preventing the self-extuation. Regular monitor and quality control plan
were executed to maintain the quality of care.
Results
The results of this study, the incidence of unplanned extubation dropped from 0.43% to 0.00% in neurosurgy intubated
patients.
Conclusion
Unplanned extubation caused great loss and injuries on both patients and health care system, and it also reflect the
defect of nursing care. Establishment of good standard of care is the best way to prevent unplanned extubation and
improve the patient safety of endotracheal tube.
Using high-risk assessment tool of self-extubation, set up the standards of sedative drug, use, mnemonics of
endotracheal tube care process and addition of glove-type restraint band to curb the self-extuation could reduce the rate
of unplanned extubation.
0591
An integrated and intensive day-rehabilitation model for patients after total knee replacement (TKR) in Pamela
Youde Nethersole Eastern Hospital (PYNEH)
1
1
2
3
Sambo Wan , Joanie Yeung , W.L Tsang , Loretta Yam
1
2
Physiotherapy Department, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong, Orthopaedics and
3
Traumatology Department, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong, Pamela Youde
Nethersole Eastern Hospital, Hong Kong, Hong Kong
Objective: To evaluate the effectiveness of a short course of intensive day-rehabilitation in a new Multidisciplinary Day
Ward (MDW) setting in improving the clinical outcome of patients after total knee replacement (TKR) in PYNEH
Method: Traditionally, TKR patients were discharged 14 days after operation and then attend 12 sessions of standard
rehabilitation sessions in physiotherapy and occupational therapy clinics. A new MDW was established in PYNEH in
October 2009 to facilitate early discharge and improve patient outcome after TKR through integrating all the elements
essential to rehabilitation in one setting: medical, nursing, physiotherapy, occupational therapy, speech therapist,
prosthetist/orthoptist, dietician and social worker (the latter four engaged on ad hoc basis). After MDW was established,
TKR patients were discharged early and referred to attend MDW day-rehabilitation service for not more than four days
within the first two weeks of discharge, followed by clinic rehabilitation to make up to a total of not more than 12
rehabilitation sessions. Using retrospective record review, comparisons were made between a historical cohort of patients
who had joint replacement in 2008 (2008 group) before MDW and those receiving MDW services (MDW group) in terms
of duration of hospital stay from D0 (defined as the day of operation) to discharge (LOS), and duration of the rehabilitation
program defined as D0 to day of discharge from clinic rehabilitation due to achievement of maximum OKS (LORP). The
functional outcome using Oxford Knee Score (OKS) was measured in the MDW group and compared with another small
cohort of patients who had TKR immediately before MDW.
Results: Retrospective review of medical records was conducted for a historical cohort of 79 patients who received TKR
from Jan to Dec 2008 (2008 group) and 84 patients who received TKR and MDW service (MDW group) from Sep 2009 to
Sep 2010. Demographic data of both groups were similar. MDW group showed significant reduction in LOS (2008 group
14.1days; MDW group 9.6days; p<0.05) and LORP (2008 =129.2days; MDW=84.1 days; p<0.01). Compared to 18
patients who had TKR immediately before MDW services (Pre-MDW group) from Jun to Sep 2009, MDW group had no
significant differences in OKS (Pre-MDW 20.3, MDW 19.7), but also had significant reduction in LOS (Pre-MDW 12.6days;
MDW=9.6days) and LORP (Pre-MDW 148.2days; MDW 84.1 days).
Conclusions: The provision of an integrated and intensive day-rehabilitation service in PYNEH multi-disciplinary Day
Ward was effective in reducing the duration of hospitalisation and of rehabilitation period of patients after total knee
replacement while maintaining similar functional outcome. We expect these results to be translated to reduced patient
risks associated with hospitalisation, better quality of life and earlier return to normal daily living and work. We have thus
shown that it is feasible to reduce hospitalisation after total knee replacement and will further refine our practice with
extension of MDW to accommodate patients after hip replacement.
0595
Review of ‘Fall Management’ through Patient safety rounds in acute/ rehabilitation hospitals.
Michelle Yuk Yi Wong
Hospital Authority, Hong Kong
Objectives:
‘Fall Management’ in acute/ rehabilitation hospitals was reviewed through Patient safety rounds with the aim of enhancing
current practice of fall prevention.
Methods:
Patient safety rounds were made by team of hospital managers as regular clinical visits during the study period. During
the visits, current practice of fall prevention is observed and the potential problems in the care process that may contribute
to a fall discussed with frontline staff. Meeting was held among the team at the end of each visit to consolidate findings.
Learning points and concerns were identified and recorded. Subsequently, appropriate strategies for risk reduction and
care improvement were consolidated.
Results:
A number of factors are found to be affecting fall management in the clinical areas:
1. Environmental factors
The environments in some wards are observed to be congested with busy traffic. Storage of appliance and
equipment in corridor is noted due to limited storage space. Extensive use of extension wires and cords was noted
due to lack of socket. The above condition may increase the risk of fall for patient.
2. Information and training
There is no policy from Hospital Authority on the issue of fall management; cluster protocol is available and well
known to staff. Departmental policy and guidelines are developed in most Departments. Orientation to new staff is
provided by all Departments but not all the content of orientation is specified and documented. Hospital refresher
training is available to supporting staff but not to Nurses.
3. Fall assessment and communication of risk identified
Fall assessment is adopted by most in-patient units and performed by nurses upon admission. (E.g. Morse fall
scale).Some Departments have developed assessment form for specific use. Staffs were briefed on departmental
practice for use and review of fall assessment. Fall assessment are evaluated regularly and repeated as required. Fall
preventive strategies were implemented as required. However, there is no common assessment tool among
disciplines and departments making it difficult to communicate assessment result and unify care. Preventive
strategies are implemented according to risk identified. Fall risk is communicated through signage, hand-over and
remarks in case- notes. However, diversified signs used in different wards could be confusing to staff of supporting
team and allied health as well as the patient’s relatives.
Conclusions:
According to the findings of the Patient safety rounds, a number of factors affecting ‘fall management and prevention
at the clinical settings were identified. Merely asking the frontline staff to be more ‘careful ‘ is not good enough,
recommendations are made for enhancement in different areas to reduce the risk and severity of patient fall:

Review and update Departmental policy and guidelines on fall prevention in line with cluster protocol.

Review and refine assessment forms in use, ensure staffs are familiar with application and implications.
(Fall prevention interventions)

Reinforce training and orientation on fall risk assessment and prevention.

Education of patient and relative on fall prevention.

Strengthen communicate on fall assessment and prevention e.g. through standardization of alert signs.

Reinforce safe application of safety vest and restraint.

Enhance multi- disciplinary collaboration in intervention.( e.g. Nursing, PT, OT)

Trial of fall prevention equipment/ facilities such as alarm mattress, hip protector and soft floor padding.

Encourage good house keeping and plan for environmental improvement.
0596
IMPROVEMENT IN PRESERVATION AND DRUG EXPIRATION AFTER ACCREDITATION
M Castellano-Zurera, JA Carrasco-Peralta, D Núñez-García, A Torres-Olivera
Andalusian Agency for Health Care Quality, Sevilla, Spain
Objective:
To spread the critical points found, and the areas of improvement implemented, during the processes of certification of
health care units in Andalusia (Spain), in relation to the preservation and drug expiration.
Methods:
This work was carried out by the Andalusian Agency for Health Care Quality (ACSA). After the evaluation of 194 health
care units, a problem was identified in the standard relating to the correct preservation and drug expiration.
Retrospective descriptive study. (N = 64health care units in which the object of study standard was not fulfilled).
Key steps carried out: [1] Extraction and treatment of the records of the processes of accreditation of the health care units.
[2] Selection of the data associated with the analyzed standard (critical points found by the evaluators in the evaluation
visits and improvements implemented by the health care units). [3] Statistical treatment of the information.
Timeframe: April 2004 to May 2010.
Source used: records included in the specific online tool for the accreditation of the health care units, called ME_jora C.
Study variables: [1] critical points [2 ] improvements implemented.
Results:
Of the 64 health care units that did not fulfil the analyzed standard, expired medicines were found in 46 (71.87%), badly
conserved medicines in 44 (68.75%), and medicines without an expiry date in 26 (40.62%). In the 64 units, more than one
critical point were identified.
The main improvements implemented by the units were grouped as:
•
Directed to avoiding expired medicines: elaboration of procedures (35%), allocation of responsibilities (22.14%),
reduction of the medicines stock (11.44%), circulation of procedures to the professionals (10%), others (21.42%).
•
Directed to avoiding badly conserved medicines: daily records of the temperature of the refrigerators that contain
thermo-sensitive medicines (31.10%), procedure to be followed in the event of an interruption in refrigeration (28.38%),
purchase of devices to control the temperature of the refrigerators (24.32%), others (16.20%).
•
Directed to avoiding medicines without expiration date: dating multi-dose packages (37.04%), re-packing / relabelling blister packs (29.63%), others (33.33%).
The implemented improvements have been maintained in 68.2% of the health care units.
Conclusions:
The certification process has enabled the health care units to implement improvements in relation to the preservation and
control of expiry of medicines, guaranteeing the more effective and safe availability of medicines. The main improvements
implemented are easily approached by other units.
After the analysis of the data obtained from the evaluated health care units, ACSA has issued recommendations to the
health care units of the Public Heath System of Andalusia.
0599
Opportunity algorithm analysis of the importance of medical service and satisfaction in the emergency
department
H. M. Huang, H. O. Kao, S. j. Lin, S. C. Chen
National Taiwan University Hospital, Taipei, Taiwan
Objective: The purpose of this study were twofold: (1). to explore the degree of the importance of medical service and
satisfaction from the perspective of patients in the emergency department(ED); (2). to understand the differences between
the importance of medical service and satisfaction.
Methods: A cross-sectional design was conducted for the study. A questionnaire with seven aspects was used to
measure patients’ perception on the degree of importance and their satisfaction on medical service. During 2009/06/16
and 2009/08/14, patients visiting the hospital to leave and return home after their emergency department visit were
included. A total of 610 structured questionnaires were distributed to ED patients with 561 of them returned. The
response rate was 91.97%. The descriptive statistics and Spearman’s rank correlation coefficient were used to analyzed
data.
Results: The scores of the degree of importance on medical service from the highest were the treatment progress (4.46),
professional competence (4.45), services (4.40), equipment (4.36), waiting time (4.29), attitude (4.27), and environment
(4.09). The scores of the satisfaction from the highest were the attitude (4.07), treatment progress (4.0), professional
competence (4.0), services (3.92), equipment (3.76), waiting time (3.67), and environment (3.61). There was a positive
correlation between the degree of importance and the satisfaction of medical services (r= .42, p＜.001). That is, when the
overall satisfaction score increased, the score of the degree of importance of medical service increased as well.
Furthermore, Four factors including the waiting time for admission, the waiting time for seeing a doctor, cleanness of
restrooms, and the waiting time for the operation are the most potential business variables by applying the opportunity
algorithm analysis.
Conclusions: The findings of current study provide useful information for improving ED service since the comments were
from the point of views of consumers. Further intervention study may be need.
Key words: Opportunity algorithm, importance, satisfaction.
0601
Audits of Clinical Records in the Professional Competence Accreditation Process: the submitted proofs
verification.
José Julián-Carrión, Manuel Ceballos-Pozo, Ana Rojas-de-Mora-Figueroa, Antonio Almuedo-Paz
Andalusian Agency for Healthcare Quality (ACSA), Sevilla/Andalusia, Spain
Objective:
To analyze the Audit Process development as an instrument to check the veracity of the information submitted by
professionals during their Accreditation Process.
Methods:
1. Subject of study: Accredited healthcare professionals
2. Scope: Public Health System in Andalusia (SSPA)
3. Timeframe: October 2007 - October 2010
4. Sample size: 3442 healthcare professionals accredited by the Andalusian Agency for Healthcare Quality
5. Type of design: Descriptive analysis
6. Instrument: Audit Process of the Accreditation Department for the continuous professional development through which
it can be seen if the accredited professionals’ clinical records match the proofs they submitted in their accreditation
projects. This process could lead to an adjustment of the result if necessary. In addition, this process uses the sampling
procedures for inspection by attributes according to the rule UNE 66020 and it takes into account the number of projects
to audit in order to be statistically significant compared with certification results published that year, with a 95% confidence
interval and a 0.05% standard error.
Results:
Out of 3442 accredited professionals, 302 were audited (8.77%). They work in all the SSPA healthcare levels. Of the 302
audited professionals, 197 have definitive results and 105 are in the last audit phase and so are awaiting result. 169 of
these professionals with definitive results passed the audit (85.79%).
The following table shows this information divided by assessment calls:
CALLS
ACCREDITED
AUDITED
% PROJECTS WHICH PASS THE AUDIT
OCT-DEC 2007
268
24 (pilot proof)
54.17%
APRIL-MAY 2008
340
Audit Process Redefinition
OCT-NOV 2008
283
36
86.11%
APRIL-MAY 2009
300
31
87.10%
SEPT-OCT 2009
460
47
91.49%
APRIL-MAY 2010
783
59
93.22%
SEPT-OCT 2010
1008
105*
In process
TOTAL
3442
197 (* 302 including the
last call)
85.79%
Conclusions:
The number of projects which don’t pass the audit has been decreasing significantly. The obtained results make evident
the veracity of the proofs submitted by professionals in their Accreditacion Projects and show the commitment of the
SSPA professionals who undertake the Accreditation Process to Continuous Improvement in their Professional Skills and
with the quality guarantee of the services they provide.
0606
MONITORING OF THE IMPROVEMENTS IMPLEMENTED IN RELATION TO THE PRESERVATION AND DRUG
EXPIRATION
M Castellano-Zurera, D Núñez-García, JA Carrasco-Peralta, R Burgos-Pol
Andalusian Agency for Health Care Quality, Sevilla, Spain
Objective
To evaluate the effectiveness during the improvements implemented by the health care units in which critical points were
identified in the processes of preservation and drug expiration.
Methods
In 2009, the Andalusian Agency for Health Care Quality made two monitoring visits to certified health care units, at two
and four year intervals from obtaining certification, with the intention of verifying the fulfilment of standards over time. One
of the standards evaluated during these visits related to the control of preservation and drug expiration.
Retrospective descriptive study. (N = 22 health care units).
Key steps carried out: [1] Identification of the health care units with critical points in relation to the preservation and drug
expiration, and which obtained certification after the implementation of improvements. [2] Identification of those health
care units to which a monitoring visit had been made. [3] Extraction and treatment of the records of the accreditation
processes.
Timeframe: June 2009 to December 2010.
Source used: records included in the specific online tool for the accreditation of health care units, called ME_jora C.
Study variables: [1] degree of fulfilment of the standard [2] critical points found.
Results
In 68.2% of the health care units the criteria of quality demanded in relation to the control of preservation and drug
expiration had been maintained.
In those cases in which critical points were found during the monitoring visits, analysis showed that these related to the
ignorance of the professionals on the procedure of control of the preservation and drug expiration (31.57%), to the
absence of records of control of expiry (26.31%), to the presence of expired medicines (15.78%) and badly conserved
medicines (15.78%) and to the incomplete availability of procedures of control of preservation and drug expiration
(10.52%).
Conclusions
The improvements implemented by the health care units have been effective, guaranteeing a correct preservation and
drug expiration.
The accreditation programme has become a useful tool to ensure safer and effective medicines in the health care units.
The monitoring visits enable the identification of new critical points to be approached by the health care units.
0611
The Development of a Quality Improvement Hub for NHS Scotland
Jane Murkin
NHS Quality Improvement Scotland
Objective
The Quality Improvement Hub is a new NHS Scotland collaboration in quality improvement resources and expertise
aiming to enable frontline practitioners, managers and leaders to bring improvement science into their everyday work and
to support NHS Scotland to implement the Healthcare Quality Strategy.
Methods
The development of a Quality Improvement Hub has required an innovative, whole-country collaboration between key
national organisations including NHS Quality Improvement Scotland (NHS QIS), NHS Education for Scotland (NES),
National Services Scotland (NSS) Information Services Division (ISD), the Scottish Government and NHS Health
Scotland. The Healthcare Quality Strategy sets out a challenging agenda for the NHS in Scotland over the next five years,
to achieve the overall aim of improving the health and healthcare of the people of Scotland and making Scotland a world
leader in healthcare quality. The strategy acknowledges that Scotland faces a number of challenges in the delivery of high
quality healthcare services, including the current economic climate, and increases in demand by demographic, cultural
and technological changes. Achieving this ambition requires a Scotland-wide co-ordinated response, a pooling of
resources and an innovative partnership approach to support staff at the frontline to deliver against this challenge. The
work programme and deliverables for the Hub are organised around four key work streams:
•
•
•
•
Implementation support that is flexible and responsive
Education and learning opportunities that are accessible and relevant
Measurement for quality improvement that is meaningful, and
Facilitation of quality improvement networks for NHS staff.
These four work streams are underpinned by the principles of creativity and innovation. In order to support the delivery of
this demanding work programme the team is developing a support infrastructure and processes and will be testing these
processes out in a number of test sites in 2011.
Results
The success of the Hub initiative will be measured in a number of ways, including:
•
•
•
•
•
•
•
number of Improvement Programmes supported by the Hub and the impact on patient care
extent to which Hub partners commit to a national single shared agenda to support the
implementation of the Healthcare Quality Strategy
establishment of a national curriculum and faculty for quality improvement
establishment of a national community of practice to support ongoing learning and development in the
application of improvement science to improve care for patient
number of healthcare processional students actively engaged in learning or quality improvement
activity
number of quality improvement practitioners developed to expert and practitioner levels through the
Hub
extent to which the Hub develops and maintains international collaboration
In the longer term the Hub will seek to measure its impact in terms of influence and culture in the NHS in Scotland.
The Hub team are carrying out a series of board visits, providing an opportunity to engage with key stakeholders and
collect early feedback on Hub activity. Boards have been supportive of the work programme, and have noted particularly
the potential benefits of a Quality Improvement Practitioners Directory, the development of a system of brokerage of staff
to support improvement work in other boards, and the delivery of bespoke support with building capacity and capability in
boards.
“if members of the Hub team had not visited the board they the key improvement people and relevant staff wouldn’t have
had this important discussion or even have been in the same room” (quote from an Improvement Lead)
Conclusions
NHS Scotland aims to become a world leader in quality improvement and, as a key infrastructure, the Hub will support
this bold aim.
0612
Success factors in the adaptation of a health care quality accreditation model in an international context
JA Carrasco-Peralta, D Nuñez-Garcia, V Reyes-Alcazar, MM Castellano-Zurera
Andalusian Agency for Health Care, Sevilla, Andalucia, Spain
Objective
To determine the adaptations of the Programme of Accreditation of Health Centres and Units (PACyU) in Andalusia
necessary for its implementation in another country.
Methods
•
Since 2009, a collaborative project has been undertaken between the Department of Health Care Quality of
Portugal (DQS) and the Andalusian Agency for Health Care (ACSA) (Spain) for the implementation of the PACyU
of Andalusia in Portugal.
•
In 2010 the first stage of the implementation of the PACyU was made based on a defined process:
•
Evaluation of four primary health care units in Portugal.
•
Consensus Meetings for the analysis of the results of the first evaluations and identification of adaptation needs.
•
Accomplishment of new evaluations to pilot the adapted PACyU.
Results
•
The satisfaction perceived by the units regarding the usefulness of the standards of the PACyU to favour
continuous improvement was 97.5%.
•
The global evaluation of satisfaction with the accreditation process was 95%.
•
There were 3 of the 112 PACyU standards (2.6%) that were agreed to be not applicable in Portugal, through
being incompatible with its legislation and its health policies.
•
However, the three standards that will not be applied in the first stage of implementation have been marked as
improvement projects for the health system.
Conclusions
•
The implementation of the PACyU in different health care contexts is feasible by making very specific and limited
modifications.
•
Consensus between institutions based on certain objectives of quality improvement is a key success factor for the
implementation of the PACyU.
•
It is possible to convert the difficulties of adaptation of the PACyU into opportunities of improvement for the health
system that adopts it.
•
The usefulness of the PACyU for continuous improvement was met with a high level of satisfaction by the
professionals of the accredited health care units.
0616
Enhancement Program on Pressure Ulcer Prevention Management for Supporting Staff
Lai Tim, Cecilia Chau, Yin Yung, Ann Chan, Ho Yee Tsang, Yin Shan Wong
Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
Objective:
The purpose of the program was to enhance care-related supporting staff’s knowledge and skills on pressure ulcer
preventive measures, so as to increase their awareness on prevention of pressure ulcer and decrease the incidence rate
of acquired pressure ulcer.
Methods:
Pressure ulcers significantly threaten the well-being of patients with limited mobility. Prevention is the most effective
strategy in care of pressure ulcers. Therefore, the first goal of Hospital Wound Management Team (HWMT) is to prevent
the development of pressure ulcer. A prevalence survey had been carried out in January 2010 in all wards under Medical
and Rehabilitation department. The results reflected that preventive measures were implemented ineffectively in most
wards.
Then a project was conducted to improve care-related supporting staff’s knowledge and skills on prevention of pressure
ulcer. Wards BCDE2 were selected as pilot wards for implementing the Enhancement Program on pressure ulcer
prevention management for supporting staff. The other medical and rehabilitation wards became control wards.
An Enhancement Program was designed and included care-related supporting staff training, appointing Skin Care
Ambassadors, addition of pillows, formulation of mnemonic and skin care products quick guide, purchasing small
containers for individual skin care product, standardized napkin changing trolley and re-designed daily ward routine during
June 2010 to September 2010.
In evaluation, a post-prevalence survey was conducted in pilot and control wards after the implementation of the
Enhancement Program in pilot wards for 3 months. Evaluation questionnaires for supervisors, HWMT link nurses, carerelated supporting staff and Skin Care Ambassadors of the pilot wards were collected. The incidence rate of newly
acquired pressure ulcer in pilot wards was audited.
Results:
By comparing the result of pre- and post-prevalence surveys, there was significant greater improvement of the
compliance rate in pilot wards from 58% increased to 94% than in control wards. The results of the questionnaires
collected were that care-related supporting staffs’ knowledge on skin care and pressure ulcer preventive measures was
increased and they could carry out what they had learned in their daily work and communicate with nurses effectively. As
a result, they could share nurses’ workload in prevention of pressure ulcer. The job satisfaction of supporting staff was
increased. All agreed that this program should be promoted to other wards. After the Enhancement Program rolled out, no
newly acquired pressure ulcer was reported in the pilot wards.
Conclusions:
Program minimized the patient at risk for pressure ulcer development. Pressure ulcer prevention management was
implemented more effectively after incorporating into supporting staff daily routine activities. The program mobilized the
supporting staff to assist nurses to implement pressure ulcer preventive measures. Therefore the workload of nurses
could be reduced. The appointing of supporting staff as ambassadors made them feeling of involvement and increased
their work motivation. The enhancement program will be extended to all Medical and Rehabilitation wards and may be
extended to the wards of cluster hospitals.
References
Ayello, E.A., Baranoski, S., Lyder, C.H. & Cuddigan, J. (2004). Pressure Ulcers. In S. Baranoski, E.A. Ayello (Eds.),
Wound Care Essentials Practice Principles. Philadelphia: Lippincott Williams & Wilkins.
Bluestein, D. & Javaheri, A. (2008). Pressure Ulcers: Prevention, Evaluation, and Management, American Family
Physician, 10(78), 1186-1194.
Dharmarajan, T.S. & Ugalino, J.T. (2002). Pressure Ulcers: Clinical Features and Management. Hospital Physician,
March, 64-71.
0617
Program of All inclusive Care for the Elderly: An Evidence-Based Patient Centered Comprehensive, Collaborative
and Coordinated Care Model
Alakananda Mohanty
Kissito Healthcare, Roanoke, Virginia, USA
It is estimated that the older American population (Age 65 and above) is expected to increase from 35,000,000 in 2000
to 71,000,000 in 2030 comprising roughly 20% of the U.S. population. The health care needs of this age group are
disproportionately high and clinically complex, and it is expected that approximately 70% of people over age 65 will
require some form of long-term care assistance and services because of their chronic illness or disabling conditions.
Furthermore, nearly 20% of Americans age 65 will live in a nursing home for at least one year with 5% spending at least
five years in a nursing home facility. It is also estimated that there are more than 3,000,000 Americans of all ages whose
mix of serious disability and chronic illness places them at the highest risk for functional decline, hospitalization, or nursing
home placement. providing affordable, comprehensive and portable health coverage for every American;
In 2010, the average daily cost of a private nursing home room was $247 or $90,155
annually. It is a matter of grave concern when the federal and state governments are struggling to contain the spiraling
health care cost and improve the quality of patient care while promoting prevention and strengthening public health across
the country.
Among the few initiatives those have been able to improve healthcare financing and the delivery of care to chronically ill
and disabled populations in the past three decades, Program of All inclusive Care (PACE ) Model illustrates a
meaningful care delivery reform for vulnerable and chronically ill populations . PACE has proven to be a highly successful
model demonstrating significant health outcomes and at a much reduced cost.
This model offers access to the full continuum of preventive, primary, acute, rehabilitative, and long-term care services for
frail and elderly while integrating all Medicare and Medicaid services into one seamless service package for beneficiaries.
Improved outcomes include fewer hospitalizations, fewer nursing home admissions, higher contact with primary care,
longer survival rates, better health, better quality of life, greater satisfaction with overall care arrangements, and better
functional status.
Therefore, PACE is a very logical approach to the above mentioned, offering all Medicare and Medicaid services through
a single point of delivery targeted to frail elderly with a host of chronic care needs. As on January 2011, there are 74
PACE programs in 31 states catering approximately 17,000 frail and elderly individuals across the United States (National
Pace Association) which needs to be considered seriously and to be expanded.
0618
Is Higher Quality Associated With Lower Racial Disparities in Cardiovascular Care?
2
1
1
Karen Joynt , E. John Orav , Ashish Jha
1
2
Harvard School of Public Health, Boston, MA, USA, Brigham and Women's Hospital, Boston, MA, USA
Objective: Acute myocardial infarction (AMI) and congestive heart failure (CHF) are two of the most common causes of
hospitalizations and readmissions in the Medicare program, and prior studies have shown that black patients have higher
readmission rates at 30 days than white patients. However, we know little about why these disparities exist. Many
policymakers believe that improving quality overall should reduce or eliminate disparities. We sought to determine
whether high-performing hospitals, defined as those with low overall readmission rates, would have lower racial disparities
than poorly-performing institutions for this same measure.
Methods: Using national Medicare data, we examined all hospitalizations for patients 65 years of age or older, enrolled in
Medicare fee-for-service, admitted with AMI or CHF in 2006-2007. We divided the hospitals in our sample into quality
quartiles based on their risk-adjusted 30-day readmission rates over this time frame for each condition. We used
weighted linear regression models to examine the difference in readmission rates for black patients versus white patients
within each quartile.
Results: Hospitals in the highest quality quartile served a lower proportion of black patients, and had a patient population
with a higher prevalence of chronic kidney disease, valvular disease, and peripheral vascular disease, but a lower
prevalence of diabetes and hypertension. Hospitals in the highest quality quartile were more often medium or large in
size, non-profit in ownership and had higher nurse-to-census ratios. Overall, in the national sample, black patients had
higher readmission rates than white patients for both conditions (for AMI, 24.3% versus 21.2%, p<0.001; for CHF, 27.5%
versus 26.2%, p<0.001). In analyses adjusting for patient characteristics, racial disparities were comparable across all
four quality quartiles: although there were large differences in readmission rates overall across the four quartiles,
disparities were comparable or greater in the high performing hospitals compared to poorly-performing hospitals for both
conditions (at high performing hospitals for AMI, 13.7% versus 16.5%, disparity 2.8%, p<0.001; for CHF, 19.8% versus
21.0%, disparity 1.2%, p<0.001; at poorly performing hospitals for AMI, 34.6% versus 37.0%, disparity 2.4%, p<0.001; for
CHF, 35.0% versus 35.1%, disparity 0.1%, p=0.81). A test for interaction (between quality quartile and racial disparity)
was not statistically significant. Further adjusting our analyses for length of stay, hospital characteristics, and the
proportion of Medicaid patients at each hospital did not alter the results.
Conclusions: We found no relationship between a hospital’s overall performance on readmission rates and its degree of
racial disparity for readmissions after hospitalization for two common, costly cardiovascular conditions. These findings
suggest that for policy makers seeking to address persistent racial disparities in readmission rates for AMI and CHF,
quality-improvement efforts alone may not be enough to eliminate disparities in cardiovascular care. New efforts that
focus specifically on disparities, and why they exist, are needed to eliminate gaps in care.
0619
Did public reporting improve patient outcomes in the United States from 2002-2008?
1
3
2
Karen Joynt , Amitabh Chandra , Ashish Jha
1
2
3
Brigham and Women's Hospital, Boston, MA, USA, Harvard School of Public Health, Boston, MA, USA, Harvard
Kennedy School of Government, Cambridge, MA, USA
Objective: Public reporting of hospital performance in the United States became widespread in late 2004, when the
Hospital Quality Alliance (HQA) was launched. Led by the Centers for Medicare and Medicaid Services (CMS) and others,
this program linked Medicare payment updates to hospitals’ submission of quality measures for congestive heart failure
(CHF), acute myocardial infarction (AMI), and pneumonia, leading to participation rates exceeding 98%. Public reporting
of hospital performance has been widely touted as a tool to drive improvements in health care quality. Recent data
suggests that public reporting may improve performance on processes of care. However, whether it improves patient
outcomes remains unclear. Advocates argue that improvements in evidence-based processes should lead to better
patient outcomes. Critics worry that public reporting leads to “teaching to the test” and will ultimately harm patients. We
sought to determine whether the CMS national public reporting program has led to improvements in patient outcomes.
Methods: Using national inpatient Medicare data, we examined outcomes for over 17 million patients 65 years of age or
older, enrolled in Medicare fee-for-service, admitted to U.S. hospitals with AMI, CHF, or pneumonia between 2002 and
2008. We examined trends in risk-adjusted 30-day mortality rates for the three publicly reported conditions: AMI, CHF,
and pneumonia. We considered 2002 through 2004 to be the pre-reporting period and 2005 through 2008 to be the postreporting period, and additionally performed a series of sensitivity analyses that varied the cutpoint for pre-reporting
versus post-reporting. We performed linear regression analyses to determine if trends in mortality changed as a function
of the implementation of public reporting. Our analysis only included the 3,617 hospitals that were participating in the
HQA public reporting program as of the end of 2004.
Results: Risk-adjusted mortality fell for all three conditions between 2002 and 2008. However, for AMI, mortality
decreased at a rate of 0.38% per year pre-reporting and 0.31% per year post-reporting (change of +0.07% per year,
p=0.04). Similarly, for CHF, mortality was decreasing at a rate of 0.21% per year pre-reporting, versus decreasing 0.09%
per year post-reporting (change of +0.12% per year, p<0.001). For pneumonia, mortality was decreasing at a rate of
0.48% per year pre-reporting, and this was unchanged post-reporting at 0.49% per year (change of -0.01% per year,
p=0.50). None of the alternative cutpoints we explored in sensitivity analyses suggested an improvement in mortality in
the post-reporting period.
Conclusions: Mortality improvements began prior to the onset of public reporting for all three publicly reported conditions
and actually slowed after the implementation of public reporting for AMI and CHF. Public reporting had no impact on
trends in mortality for pneumonia. Understanding the impact of public reporting on patient outcomes is central to
determining its value as a policy tool. These findings offer little evidence that the improvements in mortality for AMI and
CHF over the past decade are due to public reporting and raise concerns about the utility of relying on public reporting
alone as a major driver of improvement in clinical outcomes.
0621
High 5s Project – Adaptation and Implementation of International Standardized Operating Protocols for Patient
Safety in Germany
1
1
2
1
Liat Fishman , Daniela Renner , Constanze Lessing , Christian Thomeczek
1
2
Agency for Quality in Medicine, Berlin, Germany, Coalition for Patient Safety c/o Institute for Patient Safety of the
University of Bonn, Bonn, Germany
Objective
The objective of the WHO initiative “Action on Patient Safety: High 5s” is to implement and evaluate standardized
operating protocols (SOPs) in a multi-national learning community in order to improve patient safety in hospitals. The
process for adaptation of the international patient safety tools to the German hospital context is presented.
Methods
High 5s SOPs have been developed for three topics which have been identified in the literature as relevant risk areas of
hospital care: namely, 1) correct site surgery, 2) safe management of concentrated injectable medicines, and 3) assuring
medication accuracy at transitions of care (medication reconciliation). In Germany the High 5s project receives funding
from the Federal Ministry of Health and is jointly coordinated by the German Agency for Quality in Medicine and the
German Coalition for Patient Safety. Using the Correct Site Surgery SOP as an example, the national and hospitalspecific adaptation of the SOP, which was developed in the US, is presented. The core element of this SOP is a surgical
checklist which is used for both SOP implementation and collection of data for evaluation purposes. 18 German hospitals
of various levels of care were recruited to participate in this module. Joint workshops were held with these hospitals where
the SOP and the surgical checklist were adapted to the needs of the German hospitals.
Results
Any adaptations were reported back to the international project committees, which in turn triggered amendments of the
SOP at an international level. Moreover, it was necessary to incorporate the SOP into already existing preoperative
processes in the participating hospitals. Thus 11 different checklists were developed that – depending on the hospitals’
needs – contain additional elements while maintaining standardisation as according to the High 5s minimum criteria.
Conclusions
In the course of the project it became evident that simply translating the international SOP materials to be used in
Germany does not suffice. Although certain minimum criteria must be met to maintain process standardisation,
adaptations at both a national and hospital level are required in order to ensure acceptance and thus successful
implementation of the SOPs.
Acknowledgement sentence
The High 5s Project is a joint collaboration of WHO Patient Safety, the WHO Collaborating Centre for Patient Safety
Solutions (Joint Commission International) and Lead Technical Agencies including: Australian Commission in Safety and
Quality in Healthcare, Canadian Patient Safety Institute, French National Authority for Health, German Agency for Quality
in Medicine and German Coalition for Patient Safety, Dutch Institute for Healthcare Improvement-TNO, Singapore Ministry
of Health, National Patient Safety Agency (UK), Agency for Healthcare Research and Quality (USA).
0623
Evidence based approach in nursing patient with total joint replacement: Introduced an evidence based clinical
protocol on prevention of deep vein thrombosis (DVT)
Elaine W Y WONG, Oscar K F WANG
Queen Elizabeth Hospital, Hong Kong
Objectives:
In order to improve the quality and safety of patient undergoing total joint replacement, a specific emphasis on
development of an evidence-based clinical protocol, with appropriate risk assessment tool and implementing evidencebased preventive measures for deep vein thrombosis was identified.
Background of our setting:
Pharmacological prophylaxis is not a routine prevention to all patients with such planned operation, unless those who
have significantly high risk factors. Neither graded compression stocking nor sequential compression device were
available in our department before the program. Discussion has been made between nurses and clinicians and decided to
introduce these devices.
Methods:
A retrospective record review was carried out for annual incidence of post-operative DVT among those who have
undergone total joint replacement.
An evidence based clinical protocol was then developed to guide the assessment and implementation of preventions.
In constraint with scarce resource, a risk assessment tool – Autar DVT scale, is essentially cost-effective when
considering the priority in prevention.
For those who were identified as high risk subjects, Anti-Embolitic Stockings (AES) and Sequential Compression Device
(SCD) will be offered. Otherwise, Graded Compression Stockings (GCS) will be provided as a minimal prevention.
The incidence has been recorded and risk reduction was calculated for evaluation. Besides, patients’ satisfaction and
compliance were recorded and staff awareness of complication and compliance to the preventive measures were
compared.
Results:
The annual incidence one year before the program was 1.83% among all patients with total joint replacement.
Ever since the introduction of the clinical protocol, no DVT was noted among this group of patients for the consecutive 2
years. The risk reduction is 100% since no new case of DVT noted.
Besides, patients showed satisfaction on the application of preventive devices and no significant compliant on any
adverse event. It gained 100% of compliance from patients too.
Staff showed positive feedback on the increasing knowledge and awareness of such complication. The compliance in
providing risk assessment is 96% at the first year, and then 100% in the second year. Staff compliance on provision of
appropriate preventive measures is 100%.
Conclusion:
Deep Vein Thrombosis is a common and yet preventable complication after total joint replacement, many researches
have been done on both pharmacological and mechanical preventive measures. This program aims at collaboration with
the concept of evidence-based practice into clinical service in order to achieve excellence in quality and safety in our
service. And the results showed that it is indeed effective in providing prevention and yet cost-effective in alleviating
patient suffering.
0624
Hospital Acquired Infections: Development and Validation of a Predictive Model Using Automated Clinical Data
Ying Tabak, Phillip Francis, Xiaowu Sun, Richard Johannes
CareFusion, Marlborough, MA, USA
Background and Objective: Hospital acquired infection (HAI) is associated with increased mortality, morbidity, and cost.
A clinically valid and low cost risk adjustment model would aid quality improvement efforts and performance comparisons.
We sought to develop and validate a predictive model for HAI using clinical and administrative data captured in the
electronic medical record (EMR) system.
Methods: We analyzed EMR data from 2006 to 2008 for 6 US hospitals in a research database from CareFusion (San
Diego, CA, USA). The data set consisted of patient level demographic, microbiologic, general laboratory, diagnosis, and
procedure data. We randomly split 50% patients into the derivation and validation cohorts. We developed a HAI predictive
model using logistic regression method. The HAI outcome was generated by previously validated Nosocomial Infection
Marker (NIM™) algorithms. The NIM system accounts for timing of microbiologic specimen collection in relation to patient
admission and location. We used the NIM as an electronic proxy of HAI , which has proven high sensitivity and specificity.
Candidate predictor variables included severity at admission, defined as predicted probability of death, generated from
published mortality risk adjustment models, which adjusted for age, laboratory results, and comorbidities. Additional
candidate variables included transfer from other acute care hospitals, early admission to intensive care unit (ICU),
previous hospitalization within 31 days, severe concomitant chronic diseases, principal diagnosis and procedures. We
used c-statistic to assess model predictive ability and Hosmer-Lemeshow test for model goodness of fit. We also
assessed the relative contribution of each group of variables.
Results: A total of 155,041 consecutive adult admissions (age >17 y) were included in the study. The median age was 65
(IQR: 48, 78) and 57% were women. The HAI rate was 4.0% (6,134/155,041). Compared to non-HAI patients, HAI
th
patients were older (median age 72 vs. 64, p<0.0001) and sicker (57% vs. 25% in the 4 quartile of predicted probability
of death, p<0.0001). The most significant (p<0.0001) independent HAI predictors included admission severity. The
multivariable adjusted HAI odds ratios (95%CI) were 2.38 (1.98, 2.86), 4.23 (3.56, 5.03), and 7.38 (6.22, 8.74) for patients
nd
rd
th
st
in the 2 , 3 , and 4 quartiles of admission severity, compared to patients in the 1 quartile. Other significant predictors
(p<0.0001) included: neurologic trauma, 3.45 (2.53, 4.72); colon resection, 2.92 (2.21, 3.87); cachexia 2.50 (2.24, 2.80);
transferring from other acute care hospital 2.09 (1.93, 2.27), early admission to ICU 1.88 (1.67, 2.11); and paralysis 1.60
(1.31, 1.95). The model c-statistic was 0.79 with good calibration for both derivation and validation cohorts (see chart
below). The relative contribution to the model fit was 48% (admission severity), 26% (comorbidities), and 26% (ICU
admission, transfer, and previous healthcare exposure) respectively.
Model Calibration by Derivation and Validation Cohorts
Observed HAI Rate
16%
Derivation
Validation
12%
8%
4%
0%
0%
4%
8%
12%
16%
Predicted HAI Rate
Conclusions: Using automated clinical and administrative data captured in the EMR system, we developed and validated
a HAI predictive model which shows good discrimination and calibration. Risk factors indicating disease severity on
admission, severe comorbidities, and previous healthcare exposure are highly associated with HAI risk for the index
hospitalization. This model may aid HAI prevention, risk adjusted HAI comparison and performance reporting.
0625
Evidence based approach in prevention of Extended spectrum beta-lactamases (ESBL) cross infection.
Silvia C F Lee, Elaine W Y Wong
QEH, Hong Kong
Objective:
An epidemiological study was held in order to combat with Extended-spectrum β-lactamase (ESBL)–producing gramnegative bacteria, to analyse the risk factors and proposed an intervention strategy in preventing cross infection of ESBL
among orthopaedics patients
Methods:
There is an increasing incidence of patients having positive cultures of ESBL, especially in urine culture. Therefore,
current practice on infection control measures has been critically reassessed. In order to maintain the quality standard of
infection control measures during napkin round, we have assigned each of the designated team in-charge to supervise a
junior staff or health care assistant. According to infection control guidelines, change of gloves and using alcoholic hand
rub between handling different patients’ urine is suggested; however the compliance to meet the target is the main
objective of supervision in practice.
A cross-sectional point prevalence of patients having ESBL positive has been obtained before the introduction of
intervention. The intervention includes one-to-one supervision on the compliance of changing gloves and using hand rub
between handling two patients. Then collection of data on new case of positive culture of ESBL has been recorded for a
period of two months. During these two months, all staff has been briefed on the intervention strategy, and the compliance
has been under silent audit.
Results:
The cross-sectional point prevalence of patients having ESBL positive is 11.4% (5 out of 44 patients) in October. The
collection of data has been carried out for 2 months. For the first month, there are 4 new cases of ESBL among 125 newly
admitted patients, 2 of them have it on admission, as they were transferred from other institution. Therefore, the incidence
rates of ESBL drop to 1.6% (2 out of 125). In the second month, even our newly admitted patient had shot up to 146.
There was no new ESBL cases found. The incidence rates were further drop to 0% (0 out of 146).
While working on data collection, the silent audit was held at the same time among 33 core staff in our ward. The
compliance rate of changing gloves was 100%, whereas the compliance rate of using alcoholic hand rub was 87% (29 out
of 33)
Conclusions:
As ESBL producing bacteria are emerging pathogens nowadays, to combat with the cross infection has been an
important issue. In order to maintain the quality of standard in our service, it is a good practice in critically reviewing it
regularly, to identify any gap of service and make improvement accordingly. This study have achieved its objective as it
identified the gap in our quality of care and provide evidence that even a minimal procedure can contribute a great clinical
outcomes. Ultimately, continuous quality improvement is always the global momentum in patient safety.
0628
Hospital Pay-for-Performance in the United States – Do National Comparisons Work?
2
1
1
Nikolas Matthes , Rainer Hilgenfeld , Karol Wicker
1
2
Press Ganey Associates, Baltimore, Maryland, USA, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Objective:
Explore how hospital characteristics affect hospital pay-for-performance scores under the Value-based Purchasing (VBP)
initiative in the United States.
Background:
In January 2011 the United States’ Centers for Medicare and Medicaid Services (CMS) released the proposed
methodology for hospital pay for performance, called Value-based Purchasing (VBP), placing 1% of baseline Medicare
Diagnosis-related Group (DRG) payment at risk for fiscal year 2013. Hospitals will be scored on improvement and
achievement in 17 clinical measures and 8 satisfaction measures compared against hospitals nation-wide without
stratification by hospital characteristics.
Methods:
Using publicly available VBP scores for 3211 acute care hospitals for the assessment period and prior year baseline
period, we analyzed the distribution of overall VBP clinical and satisfaction scores across hospital characteristics including
region, hospital type, teaching status, location and bed size using SAS.
Results:
Distribution patterns of clinical and satisfaction scores are not consistent across hospital characteristics. Ranks of
subgroup averages are different as confirmed by the low rank correlation (0.13) between the clinical and satisfaction
domains. Distributions of VBP scores for region, teaching status, bed size are mainly determined by satisfaction score
since variation of the clinical scores are insignificant (<3%). Distributions for hospital type and location are determined by
clinical score due to its significant variations (>10%) and higher weight (70%). High performing groups are South/Midwest,
bed#<100, for profit, non-teaching and urban, low performing are West, bed#>=300, government, teaching and rural.
Conclusions:
With the impending implementation of VBP in the United States, significant variation of scores raises important health
policy questions since the approach stipulates that hospitals are compared nation-wide without stratification by, or
adjustment for, hospital characteristics. If scores vary, payment and public reporting of the results may need to be
adjusted. If other countries are planning pay-for-performance initiatives based on relative performance, variation and
patterns of performance based on hospital characteristics should be explored.
0630
Comparison of hospital discharges at a Brazilian healthcare plan hospital network using Geoprocessment and
Diagnosis-Related Groups (DRG)
Fernando Martín Biscione, Jean Charles Sousa, Mônica Silva Monteiro de Castro, Fábio Leite Gastal
Unimed Belo Horizonte, Belo Horizonte/Minas Gerais, Brazil
Objective: To compare hospital discharges at a Brazilian healthcare plan hospital network using Diagnosis-Related
Groups (DRG) weights and geoprocessment techniques, with focus on the geographic region of origin of the beneficiaries.
Methods: Belo Horizonte (BH) is the capital city of Minas Gerais state, south-eastern Brazil. Our institution, Unimed Belo
Horizonte, is a medical cooperative healthcare plan with almost 1 million clients residing mainly in the BH metropolitan
area, although patients from all over the country are admitted in its hospital network. This research used All-Patients DRG
(v21.0) to compare and evaluate hospital discharges at 59 hospitals from January 2007 to December 2010 of
beneficiaries whose geographic origin was within Minas Gerais state. All data were obtained retrospectively from
administrative records and health plan billing system, but secondary diagnoses were not available. Applications of the
Geographic Information System were also used.
Results: Overall, 281,681 hospital admissions of patients from all over Minas Gerais state were analyzed, 14% being
patients from regions outside BH. Admissions of patients from outside BH were responsible for 17.4% of the global casemix. Within this group, Belo Horizonte metropolitan region (51.4 km apart form BH), Oeste de Minas (130.7 km from BH)
and Vale do Rio Doce (203.3 km from BH) accounted for 46.3%, 15% and 13.3% of the global case-mix, respectively,
with other regions being responsible for less than 6% each. A significant but fair positive correlation was observed
between DRG weights and mean distance from BH (Spearman's rho=0.1107, p<0.001). The mean DRG weight for
admissions from BH was 1.0 and the most frequent DRG was 119 (vein ligation & stripping), with 17,122 admissions
(7.1% admissions from BH). However, DRG 483 (tracheostomy except for face, mouth and neck diagnoses), with only
1,098 admissions (0.5%) was responsible for the largest case-mix (6%). Patients from Belo Horizonte metropolitan region
had a mean DRG weight of 1.2 and the most frequent DRG was 112 (percutaneous cardiovascular procedures without
acute myocardial infarction/heart failure/shock), with 1,004 admissions (5.2%). This DRG also accounted for the largest
case-mix (6.8%). A similar DRG frequency and case-mix distribution was observed for patients from Zona da Mata (191.6
km from BH, mean DRG weight 1.3) and Campo das Vertentes regions (156.7 km from BH, mean DRG weight 1.3).
Patients from Oeste de Minas region had a mean DRG weight of 1.3 and the most frequent DRG was 112, with 224
admissions (4.4%). However, DRG 483, with only 33 admissions (0.6%), was responsible for the largest case-mix (5.7%).
A similar pattern was observed for admissions from Vale do Mucuri (343 km from BH, mean DRG weight 1.4) and
Triângulo Mineiro/Alto Paranaíba regions (444.8 km from BH, mean DRG weight 1.3). Patients from Vale do Rio Doce
region had a mean DRG weight of 1.4 and the most frequent DRG was also 112 (252 admissions, 5.4%), but DRG 107
(coronary bypass without percutaneous transluminal coronary angioplasty with cardiac catheterization), with 85
admissions (1.8%), accounted for the largest case-mix (7.1%). Patients from Central Mineira region (140.7 km from BH)
had a mean DRG weight of 1.2 and the most frequent DRG was 232 (arthroscopy), with 94 admissions (5.2%). However,
DRG 483, with 12 (0.7%) admissions, accounted for the largest case-mix (7%). A similar distribution was observed for
patients from Sul/Sudoeste de Minas region (288.4 km from BH, mean DRG weight 1.4).
Conclusions: DRG and geoprocessment techniques are valuable resources for describing utilization patterns and casemix within a geographic region. The joint use of both tools allows the identification of areas of low and high supply of
healthcare services, the planning of resource use, and the evaluation of healthcare networks.
0632
Measuring Knowledge
1
1
2
1
Victor Reyes-Alcázar , Anailien Boza-Rivera , Antonio Romero-Tabares , Joaquin Navarro-Lizaranzu
1
2
Andalusian Agency for Health Care Quality, Seville, Spain, AETSA, Seville, Spain
The Balanced Scorecard (BSC) helps to translate organizational knowledge into objectives and actions. The classic
perspective “Learning & Growth” in the Balanced Scorecard model of Kaplan and Norton is a key element in the success
of organizations.
Objective
The main objectives of this abstract are to connect Learning and Growth under the Knowledge Management approach
with BSC, in an organization focused on health care quality, and to establish the fact that the success of knowledge
management can be measured by the Balanced Scorecard.
Methods
The methodological phases were:
(1) Review of the key success factors (KSFs) defined by the organization in its Strategic Plan.
(2) Identification of knowledge transfer as a key resource of strategic value. (3) Design of a synthetic indicator to monitor
knowledge as a KSF.
(4) Selection of the variables that compose the indicator. (5) Mathematical formulation of the equation that will allow the
integral calculation of each variable and the indicator. (6) Contextualization of the indicator within the BSC.
Context: The project was carried out in the Andalusian Agency for Health Care Quality (AAHQ), during 2010.
Results
1) The AAHQ has defined seven KSFs in their Balanced Scorecard. The KSF referring to knowledge was entitled
“knowledge as a key resource”.
2) An indicator associated to this KSF was defined: the synthetic index of scientific production (SPI – Scientific Production
Index). The SPI is made up of three specific variables, two weighting factors and one independent variable.
[2a] The three specific variables are: Number of Articles published in scientific journals (Varticle). Number of Abstracts
accepted for conferences (Vabstract). Number of Research Projects financed (Vproject).
[2b] The two weighting factors are:
* Number of different authors who participate in a project, article or abstract (WF1)
WF1= Papers with internal authors (authors within AAHQ) < Papers with collaborative authorship (authors external to
AAHQ)
* Geographic criterion of the project, article or abstract (WF2). [WF2= Regional < National< International]
[2c] An independent variable was defined, the Impact Factor of the journal where the articles are published (IF - impact
factor, published by the Journal Citation Reports)
3) Finally, the synthetic index of scientific production (SPI) is defined by the expression:
SPI= A+B+C
A= ∑ (Varticle * WF1* IF)
B= ∑ (Vabstract* WF1* WF2 )
C= Vproject* WF1* WF2
SPI= A+B+C= [∑ (Varticle * WF1* IF)] + [∑ (Vabstract* WF1* WF2 )] + [Vproject* WF1* WF2]
In the Balanced Scorecard of the AAHQ, the SPI is measured each semester. The primary data are recorded in the Data
Warehouse of the organization and are exploited by means of the QlikView tool.
Conclusions
The incorporation of a synthetic indicator of scientific production in the BSC, reflects the strategic importance that the
scientific production has in the AAHQ, and reinforces the link of the Learning and Growth under the Knowledge
Management approach with BSC.
The aim of the weighting factors is to reflect the direction of the organization towards collaborative work.
0634
Characteristics of High Performing Healthcare Services: A Review of Comparative Outcome Studies
Caroline Brand, Anna Barker, Renata Morello, Sue Evans
Monash University, Melbourne, Victoria, Australia
Objective:
How well can we measure healthcare performance and do we know which hospital characteristics amenable to
improvement are related to high performance? The object of this review was to critically appraise, comparative studies
that have investigated associations between high-level healthcare service characteristics and healthcare performance.
Methods:
Types of studies included were; multi-centre systematic reviews and/or meta-analyses, randomised trials, controlled
before and after studies or comparative cohort and cross-sectional studies.
Types of healthcare service settings ; were those that incorporated a hospital setting with or without other services such
as sub-acute or residential care, but where all services were managed by a single governance body.
Health service characteristics were included where these pertained to the overall structure of the healthcare service
and/or to healthcare service governance bodies and/or senior management.
Health care performance measures were included where these were distal health outcomes (such as mortality, adverse
events and financial outcomes) or represented intermediate impacts, such as adherence to processes of care and human
resource impacts. Performance was defined by whole of healthcare service performance rather than department or
individual performance.
The search strategy included articles published between January 1996 and May 2010 and used OVID Medline, CINAHL,
The Cochrane Library, proQuest and Psychinfo databases. Medical subject headings (mesh) terms and keywords were
used as appropriate for each database. Bibliographies of included articles were searched for additional references and
select business journals were hand searched.
Study selection and critical appraisal was performed by two independent reviewers and disagreements settled by a third
reviewer. The data was collated and grades of evidence (A strongest , B, C or D weakest) for associations between
healthcare service characteristics and performance outcomes were made based on level and consistency of evidence,
1
generalisability and applicability to the Australian context .
Results:
Over 8000 articles were screened, of which 11 systematic reviews and 49 observational articles were included for review.
Healthcare service characteristics were grouped as; environment (incentives, market characteristics), health service
structural (network membership, ownership, teaching status, geographical setting, service size), operational
(innovativeness, leadership, public reporting, patient safety practices, information technology systems, service activity and
planning, workforce design, staff education and training). Overall studies were heterogeneous in the type, definitions and
measurement of performance within each performance domain. There was no level A evidence identified to support
associations between healthcare characteristics and improved performance. There was level B evidence (trusted to guide
practice in most situations) to support an association between computerised physician order entry systems and level C
evidence (some support for the association but care should be taken in application) to support associations between
nursing leadership, staff education and workforce design, hospital volume, physician workforce design, financial
incentives and higher performance.
Conclusion:
This review has provided a comprehensive critical summary of reported associations between health service
characteristics and performance outcomes. Results pertaining to use of CPOE, nursing leadership and workforce design
can be used by governing boards with some confidence. However, there is a pressing need to gain consensus about the
definitions of performance measures to be used for comparative benchmarking purposes. There is also a need for further
investigation of poorly investigated characteristics such as medical workforce and leadership for medical and allied health
professionals.
1. Australian Government, NHMRC 2007, Canberra. [This review was commissioned by the Victorian Managed Insurance
Authority, VMIA]
0636
A Project of Enhancing Nursing Staff’s Recognition of Chemotherapy and Proficiency of Applying Port-A
Chen, Hsiang-Lan, Hu, Ya-Chuan, Chen, Shih-Wan
Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan
Abstract
The unit the authors work is the ward for neurology; at times patients in chemotherapy may be hospitalized in this
unit. In 2009, there were ten patients in chemotherapy hospitalized in this unit while there were seven from January
to June in 2010. Among the seven patients in 2010, there was a case of fluid extravasation of Port-A, which triggered
nursing staff’s fear on applying Port-A. Hence this project was started. After the six-month evaluation of the scene,
literature review, problem confirmation, improvement, educational training, techniques teaching , practice,
assessment and enhancing staff’s recognition and proficiency of applying Port-A, no more fluid extravasation
occurred in the following six patients so that the patients can be provided complete, accurate and safe chemotherapy.
Objective:
This project aims to enhance nursing staff’s recognition, realization and accuracy of applying Port-A so that the patients
can be provided complete, accurate and safe chemotherapy in order to lower the probability of fluid extravasation.
Methods:
According to the result of applying the three scales formulated by the department of Hematology and Oncology:
Recognition of Medicines for Chemotherapy Scale, Check List of Applying Chemotherapy and Check List of Applying
Port-A, the accuracy of the comprehension of medicines is 85.5%, the percentage of realization of chemotherapy is
66.35% and the accuracy rate of applying Port-A is 48.83%. All the three numbers seem to be lower than expected.
After analysis, the reason may be the nursing staff in neurology is in lack of training of chemotherapy; therefore, their
professional knowledge is sufficient and the accuracy rate is low.
Some plans for improvement are thus set up. The first one is to hold education training of chemotherapy for the purpose
of enhancing staff’s proficiency and accuracy. Second, it is supposed to be a NP to instruct relevant staff how to applying
Port-A. Third, the photos of the process of practicing Port-A and related literature should be collected for future references.
The fourth one is to make a model for practicing Port-A and for evaluation. Fifth, the training is supposed to be held and
assessed regularly.
Results:
After implementing the project, the accuracy of the knowledge about medicines for chemotherapy is lifted to 95%; the
percentage of realization of chemotherapy is 85% while the accuracy rate of applying Port-A and the caring on patients is
also raised to 80%. The nursing staff’s techniques and proficiency are indeed improved after six-month evaluation and
assessment. In the following six patients of chemotherapy, not any fluid extravasations occurred.
Conclusions:
There may be crisis or unusual occasions happening when nursing staff is required to take care of patients whose
disease is not in the department. Only when the nursing staff is trained to uplift their comprehension about the therapy
and techniques and the training is regularly assessed can the therapy be effective.
0639
Increasing the Effectiveness of a Patient-oriented Pain Free Hospital Program
Alan Talbot, Hsu-Tung Chang, Tzu-Shun Su, Wei-Chen Hsu
Changhua Christian Hospital, Changhua, Taiwan
Objective:
To extend our pain-free program for hospital patients by the addition of the American Pain Society (APS) survey, and to
increase effectiveness by giving feedback to physicians of the Pain Management Index (PMI) results.
Methods:
Our hospital, a medical center in central Taiwan, monthly patient populations are around 8,636 emergencies; 109,185
outpatients; and 4,447 inpatients. There are specialty clinics for pain control (such as cancer, postoperative, and
childbirth), but no information on whether general inpatients had pain, and if so, how well it was being managed.
Our first phase (July 2008) was to develop the infrastructure needed to provide the missing information. All routes of
patient entry (emergency, outpatients, inpatient admission) were outfitted with graphics and translations of a pain
assessment scale, ranging from 0 (no pain) to 10 (unbearable pain). Protocols were updated to make pain assessment a
mandatory part of initial patient examinations, and each nursing shift for inpatients. All staff underwent training in the new
processes.
In Oct~Dec 2009, we conducted our first audit of the implementation of these protocols. Key indicators had compliance
rates between 93%~99%: analgesics administered for pain scores of 4 or higher; reassessing pain after giving analgesic;
and reassessing pain score if score less than 4. Our 2nd phase was to add patient input as an outcome indicator.
We translated the APS patient into traditional Chinese in order to interview inpatients about their pain management. We
held multiple sessions informing nursing leaders of the results and how to use them to interpret individual ward
performance. Similar explanations were delivered at doctors’ meetings. The concept of a ‘pain-free hospital’ was
introduced.
Results:
Our website http://www.qi.org.tw/Quality/Pain/PainSurvey.aspx makes the results available. Using pain of 7 or more as
the definition of ‘ top box’ in this pain scale, 9% or patients had pain when visited, 44.7% had pain of that level during the
past 24 hours, and 14.8% indicated that that was the average level of pain they endured. Activities most affected by pain
were general activities, walking, and sleep. Despite documented pain, patient satisfaction with clinical management was
high (82%).
During the audit, we encountered problems such as initial pain assessments being completed by lower-level staff, and not
according to protocol. Since the medical record is computerized, it almost mandates that all fields have entries. We feel
the discrepancy between the audit of the first phase and the patient interviews is due to this in part. We have now made
both phases a regular part of quality improvement, with chart audit once a year, and patient interviews quarterly.
Immediate improvement was seen in the indicator measuring whether patients are advised and encouraged early in their
course to ask for help with their pain. This has risen from an initial (already high) level of 71%~95% in Q1 2010 to 100% in
nearly all wards by Q4. However, interviews documented that many patients had pain but were afraid to make it known to
medical staff.
Conclusions:
Pain in the general inpatient population is overlooked. Clinical staff may react to policy changes by robotic completion of
computer screens and not provide reliable data. Nursing staff follow fixed programs of pain assessment, but fail in
providing patient-tailored follow-up (after analgesic administration). Doctors tend to write packaged orders (e.g.
immediately after surgery) and also fail to follow-up individual patient needs. Next time: we have placed all material on elearning websites, given public praise for excellence, made results available in a timely and transparent manner to staff
and public. The APS questionnaire requires further development. Pain in the general inpatient population is overlooked
but widespread.
0640
Improvement of patient’s care through promotion of activity by hospice ward nurses
1
2
2
SHU TING HSIEH , Ching Fen Tsai , JENNY HSIEH
Chimei Medical Center, Tainan, Taiwan
Objective: Lack of exercise can aggravate symptoms, fear of activity, depression, and disuse syndrome in terminally ill
patients. This in turn will affect their quality of life. Through increasing the frequency of activities available in the hospice
ward, we hope to decrease the physical and mental suffering of the patients and increase the interaction between the
patient and their family members, thus improving the quality of life of the patient.
Method: Our project took place from September 2009 to May 2010. Through chart review and questionnaires we
confirmed the problems were as following:
1. Nurses lacked the ability to conduct activity in hospice patient.
2. A lack of standardized activity for hospice patient
3. A
4. A
lack of suited activity hospice
patient should participate in.
Before program
After program
＜3x/wk
≧3x/wk
＜3x/wk
≧3x/wk
Active range of 81％
motion exercise
19％
70％
30％
Possible solutions for the problems
include:
passive range
of motion
exercise
75％
25％
0％
100％
Wheel chair
ride
38％
62％
40％
60％
1. Design appropriate active and
passive range of motion
exercise for hospice patients
and make video tape for
viewing.
Arts & craft
100％
0％
80％
20％
Aromatic
message
100％
0％
80％
20％
Singing psalm
75％
25％
50％
50％
Karaoke
100％
0％
100％
0％
Coffee break
100％
0％
100％
0％
Frequency of
activity
on
lack of equipments needed for
activity in the hospice ward
2. Design appropriate exercise or
activity and post the schedule
billboard.
3. Purchase needed equipment for
activities.
4. Conduct continues education
for nurses on active and
passive activities appropriate for
hospice patient.
Results:
1. The frequency of activity and exercise conduction by nurses ( greater than 3 times a week), active range of motion
exercise increased from 19 to 30%, passive range of motion exercise increased from 25 to 100% (table 1)
2. Types of activity increased from 2 (singing psalm and karaoke) to 6 ( arts and craft, aromatic message, coffee breaks
and movie viewing)
Conclusion: Our program effectively increased the frequency of activities conducted by hospice nurses. Through patient
and family member’s attendance of these activities, more interaction leading to patient saying thanks, expressing love,
apologizing, saying good bye and sharing each other’s emotion; Caretaker’s willingness to actively give patient a 10 to 20
minutes of passive range of motion exercise, also increase the meaning of their companionship.
0641
Evaluation and effect of pay for performance demonstration project for acute myocardial infection in Korea
Sun-ho Joung, Hyun-Ah Ahn, Yeon-Hee Cho, Mi-La Ahn
Health Insurance Review & Assessment, Seoul, Republic of Korea
Objective
Health Insurance Review and Assessment Service(HIRA) has committed to a national Value Incentive Program(VIP;Payfor-Performance in Korea) demonstration project in acute myocardial infarction(AMI) from July 2007 to December 2010.
This study is aimed to assess the outcomes of 3 years of VIP demonstration project and analyze the effect of the
evaluation.
Methods
We analyzed the Korea National Health Insurance Claims Data and the clinical data documented by hospitals of all
patients admitted to hospitals through emergency room from July 2007 to December 2009 with AMI. A total of AMI
patients was 21,831 in 44 tertiary hospitals.
We compared using five process measures and one outcome measure (Table 1). The study used composite quality
score(CQS) calculated using a combination of six measures to judge the quality of a hospital's services for AMI. We
classified the hospitals into five groups by star rating.
The VIP demonstration project was performed over three years. The procedure was as follows:
Year 1: July - December 2007; setting penalty threshold(upper CQS of 5th group)
Year 2: January - December 2008; paying incentive to the top of 20% of hospitals
Year 3: January - December 2009: paying incentive or imposing penalty
Linear mixed model with CQS was used to compare the results between hospitals.
Results
The average CQS, aggregate of all quality measures with each hospital, improved significantly over the years(p<0.0001) ;
92.10, 93.65 and 97.38 in the first, second and third year respectively(Table 2). Variance among hospitals decreased. Any
hospitals were not penalized financially because they met the quality goals (Figure 1).
The mean percentage of each measure also improved steadily during the study period (Figure 2). The largest
improvement was in Thrombolytic agent received within 60 minutes of hospital arrival which increased from 70.3% to
91.2%. The mortality rate decreased from 7.9% in year one to 6.4% in year three, a drop of 1.5%. These improvements
saved the lives of an estimated 140 AMI patients in three years.
Table 1. Quality Measures of AMI
measures Quality Measures
1. Thrombolytic agent received within 60 minutes of hospital arrival
2. P.PCI received within 120 minutes of hospital arrival
Process 3. Aspirin at arrival
4. Aspirin prescribed at discharge
5. Beta blocker prescribed at discharge
outcome 6. Risk-adjusted 30-days mortality rate
Table 2. Composite Quality Score of AMI
N Mean Std.
Minimum Maximum p-value p-value
deviation
1st year(2007) 28 92.10 9.37
59.08
101.88
2nd year(2008) 41 93.65 7.22
64.71
100.74
3rd year(2009) 44 97.38 3.19
88.04
101.78
<.0001* <.0001**
* p-value for mean comparison by years
** p-value for trend by years
Figure 1. AMI Composite Quality Score
Figure 2. AMI measures
Conclusion
The VIP program has shown to promote increased quality improvement in AMI. The overall CQS significantly increased
and Variance among hospitals decreased. HIRA is expanding the VIP from tertiary hospital to lower group, general
hospital. We anticipate that these results would be very helpful to use VIP project in other clinical areas.
0642
Improving Voluntary Hospital Incident Reporting
Sherwin Chan, Soo Sin Chan, Benjamin Ng
Tan Tock Seng Hospital, Singapore
OBJECTIVE
The hospital’s objective is to increase the number of voluntary incident reporting as part of the hospital’s effort to improve
the culture of voluntary incident reporting for patient care improvement and safety.
QUALITY ISSUE
The hospital’s objective is to increase the number of voluntary incident reporting as part of its effort to improve the culture
of voluntary reporting for patient care improvement and safety.
INITIAL ASSESSMENT
Initially, a manual incident reporting system was established, followed by configuring hospital's internal email system for
reporting and subsequently, a web-based reporting system was implemented. Only small increment in the number of
incidents reported was observed.
IMPLEMENTATION
Measures were implemented to improve voluntary reporting. They were (1) Patient Safety Leadership Walkabout, (2) Risk
Management and Patient Safety Workshop, (3) Unit Based Quality Improvement Committee, (4) Induction Programme
and (5) Reward of the most incident reports raised.
EVALUATION
Following their implementation, increase in the number of incidents reported was observed. Regular education and
recognition of the importance and benefits of the open, voluntary incident reporting play a key role in significantly
improving the number of incidents reported.
Improvements in patient care and safety have been demonstrated with the introduction of the reporting system. For
implementation to be successful, the system needs to be easily accessible, easy to use and user-friendly. Staff training
and continuing reminder, and regular encouragement and recognition, will significantly contribute to a positive culture of
voluntary incident reporting.
LESSON LEARNT
With improved culture of voluntary incident reporting, the hospital has benefited from the ability to construct a global
picture of common institution-wide problems, allowing the hospital to channel its limited resources in an appropriate and
targeted manner, to ensure the care provided to patients are of excellent quality and safe.
CONCLUSION
The importance and benefits of the voluntary incident report system in improving patient care and safety have been
demonstrated since the introduction of such a system in the hospital. The use of a web-based incident reporting system
such as the eHOR system has shown the need to have a system that is easily accessible, easy to use and user-friendly
for the system implementation to be a success. Training for new staff and continuing reminder of staff, and regular
encouragement and recognition demonstrated by a reward system, will significantly contribute to the development of a
positive culture of voluntary incident reporting.
0643
A multidisciplinary falls evaluation programme for elderly fallers presenting to an emergency department ( ED )
reduced re-attendance and functional decline.
Chik Loon Foo, Madeline Phuah, Vivian Siu
Tan Tock Seng Hospital, Singapore
Objective:
To evaluate the effectiveness of a multi-disciplinary falls intervention programme for elderly fallers that combined on-site
multi-disciplinary assessment and management at ED, and onward referral to appropriate services to reduce the reattendance rate and functional decline.
Methods:
This is a post - test only comparison group study using historical controls, with a convenience sample of consecutive
patients presenting on Monday to Friday during office hours. The patients for the control group were recruited over a
period of two months at the beginning of the study. These control group patients received the usual ED care for their
presenting symptoms and complaints. Recruitment was performed based on similar inclusion and exclusion criterion
outlined below over the next 15 months for the intervention group.
Inclusion criteria:
1) Age 60 and above
2) Fall(s)
3) Ability to ambulate before and after fall
Exclusion criteria:
1) Falls as a result of syncope, stroke, seizure or a violent blow
2) Resident of nursing home
3) Existing follow-up with the Department of Geriatric Medicine
4) Severe cognitive impairment with inability to give consent
5) Refusal by patient / next-of-kin
These patients were seen by a an emergency physician, nurse and a physiotherapist with the aim to identify elderly fallers
with risk factors and initiate appropriate interventions. First-of-its-kind collaborations were developed for this:
1. Physiotherapy assessment for all elderly fallers, including Berg Balance Scale, gait and limb strength assessment.
2. Same-day ophthalmology referrals for patients found to have visual impairment.
3. All cases were discussed with a falls-expert geriatrician at monthly multidisciplinary meetings.
Results:
There were 177 patients in the control group recruited between 7 April and 13 June 2008, and 304 patients in the
intervention group recruited between 16 June 2008 and 23 Sep 2009. There were no significant differences in baseline
characteristics between the two groups. Majority of patients had a least one risk factor for falls. 20% of patients were
referred to a geriatric outpatient clinic. 24% had gait and balance disturbance and 12% required admission.14% were
referred to outpatient physiotherapy and 12% were referred to ophthalmology clinic. After a 12-month follow-up, there was
a significant reduction in IADL scores in the intervention group compared with the control group. Similarly there was a
significant 29% decrease in ED re-attendance (adjusted IRR 0.71,95% CI =0.57 - 0.89) and concurrent reduction in
hospitalisation (30.5% vs 20.4%) and falls rates (23.2% vs 17.4%), but these were not statistically significant.
Conclusion:
This study helped us develop first-of-its-kind collaborations between disciplines to achieve a first ED based multidisciplinary falls programme for the elderly. This program has continued to be successful in reduction of ED reattendances at our hospital and we believe that this model of care can be implemented in other areas including ED short
stay observational units to identify elderly fallers at risk.
0645
Second Global Patient Safety Challenge -- Pre procedure & Time Out check
Wai_Kwong POON, Camille, Kam Tak HO, Cynthia LITTLEBURY
Hong Kong Adventist Hospital, Hong Kong SAR, China
With reference to the ‘5 step of correct patient, correct site and correct procedure policy, 2006’ of ACT Health, Australia;
and the revised Universal Protocol 2009 of the Joint Commission International, and Association of periOperative
Registered Nurses of USA, ‘Time out is already one of the key element in pre-procedure verification process and in the
medical errors prevention and safety measures of correct procedure promotion. This was also being taken as Second
Global Patient Safety Challenge by World Health Organization. The current Cardiac Catheterisation Intervention Center
pre procedure check list cum Time Out check list is very comprehensive. It covers all important pre-procedure safety
checks with a tick just next to the items,
Pre procedure check included with 13 items: Correct patient ID, correct consent, fasting, allergies, pre-med, IV cannula,
medical notes, procedure site, dental, orientation/education, explanation; and Time Out check on correct identification,
correct consent, correct procedure. In order to promote this challenge on Patient Safety; early announcement and
awareness program was made to all staff including shift rounds and policy read and sign.
Objective:
Allow staff to be in full practice on taking Second Global Patient Safety Challenge with new checking items.
Methods:
Over the 5 weeks period between 28-4-2010 to 2-6-2010, 37 patients’ check list sheets were collected (in the interest of
producing a earlier report time, the original time frame is adjusted to 5 weeks instead of 6-8 weeks and the subject
number is close to 40, and is regarded as acceptable to proceed for the next step for data analysis.)
As per data collection method, the recording nurse photocopied the check list sheets after they were completed by the
recording nurse, though the actual checking were done by either the circulating nurse or the recording nurse, plus the
radiographer.
Results:
All patient were given orientation and education to the lab environment and explanation were also given with 100% bench
mark achieved and all check lists were signed by Nursing Staff.
Recommendations:
Although the written remark was not designed to be part of the indicator it is therefore not counted in the bench mark.
It has revealed however, the entry on the type of allergies, type of pre-med given and site of IV cannula and IV fluid in
progress are in fact very important information; and preferably to be in more details.
The current pre-procedure checklist and time out check list used in CCIC are already in line with the Universal protocol
standards, however, it is worth considering the following recommendations:
1. The addition of written clarification on which 2 identifications have been used.
2. The fasting period to be documented, it could be of significant to the Operator, in terms of hydration; risk of aspiration,
or in the case of deterioration in patient’s condition and requiring intubation. 3. Procedure Site is not pre-determined in
interventional cases thus not requiring ‘site marking’, it is however important to check potential sites, radial and/or pedal
pulses as baseline, so as to compare the neurovascular status post procedure.
4. IV cannula site and status, fluid description and rate must be documented
Periodically monitoring and auditing will still be going on to ensure safety can be sustained in view of patient safety.
Conclusion:
It is really a challenge on ensuring all staff with take the Second Global Patient Safety Challenge. However, with
commitment from Management, nursing as well as medical colleagues, and take this as an ultimate goal on patient safety,
full compliance is still be practical.
0647
The promotion of oral hygiene for patients at a hospice ward in Taiwan
JENNY HSIEH, Hsien-Chen CHANG, SHU TING HSIEH
CHI MEI MEDICAL CENTER, TAINAN, TAIWAN.
Abstract
Most terminal ill patients are unable to perform their own oral hygiene. Poor oral hygiene may induce many problems,
such as candidiasis, and tongue-coating. This may affects patient’s oral comfort, appetite and life quality. The purpose of
this project is to understand the oral hygiene conditions of patients at a hospice ward and to develop a oral hygiene
protocol to promote good oral hygiene care.
Objective
The project was carried out from March to December 2009. The status of oral hygiene was examined in 121 subjects
every Sunday from March to May. There was 31% with poor oral hygiene, 22％ with tongue-coating, 12％ with oral
candidiasis, and 2％ with retension of food debris. The factors that contribute to the poor status of oral hygiene were 1.the
lack of knowledge and skills of oral hygiene to maintain oral hygiene. 2. The inability of patient to open their mouth wide
enough for oral care. 3. Decreased immunity from use of antibiotics and steroid.
Methods
Our strategies to improve oral hygeine care are: 1. Make video tapes and pamphlets to teach the family how to properly
perform oral hygiene care. 2. Make soda water or cola gauze for those who can not open their mouth for cleaning, then
clean off the tongue-coating. 3. For those who can’t gargle, we use a 20㏄ syringe fill with green-tea to clean and suction
the oral cavity. 4. Increase bedtime oral hygiene to decrease food debris.
Result
From June to December we re-examined 251 patients, 22% had poor oral hygiene, tongue-coating droped to 16%,
candidiasis droped to 6 %, and retension of food debris drop to 1%.
Conclusions
We conclude, with regular oral hygeine evaluation and individualized education on oral hygeine, we can improve patient’s
oral hygeine status and increase the comfort level of the patient.
0648
Cross-sectoral cooperation to improve the processes of Pap smear screening for cervical cancer
Y.T.Wang, C.-M. Yang, H.Y. Tai, T.-C. Chao
Linkou Chang Gung Memorial Hospital, TAOYUAN HSIEN, Taiwan
Objective:
Cross-sectoral cooperation is used to find out the processing problems and improve the quality of pap smear.
Methods:
Pap smear is the common screening tool to detect cervical cancer. The time to collecting samples, sampling technique,
and patient’s status may affect the results of Pap smears. If the smears are not able to provide accurate information, it
may delay the possible diagnosis of cervical cancer, and in turn, patient’s health may be affected. We found that the rate
of Pap smear reports as “inadequate for interpretation” was high. The problems classified as “inadequate for
interpretation” include insufficient cervix cells, excessive blood, thick smear, drying artifact, and excessive inflammation.
We also received complaints from patients regarding the unsatisfactory reports making them to repeat Pap smear. A team
lead by the quality manager was organized and included gynecologist, pathologist, Pap smear technician, cytology
technician, and IT (information technology) man as members. Root cause analysis was performed to disclose the
underlying reasons. The major factors influencing the Pap smear results include: (1) the standard operation procedures
for making smears were well described, so the staff did not perform procedures in the same way; (2) cotton swabs, cervix
brush and cytobrush were included in the standard operation procedures as tools for collecting specimen although cotton
swabs are generally not recommended; (3) patients were not adequately educated to prepare themselves for Pap smear,
such as two days before the test, avoiding intercourse, vaginal douche, vaginal medications, and Vaginal contraceptives
such as birth control foams, creams, or jellies. In addition, we also found the patients’ information was recorded by hand
writing which would result in errors.
Changes were implemented to improve the process and results of Pap smear, including: (1) revising Pap smear standard
operation procedures; (2) discarding cotton swabs for collecting specimen; (3) making a video teaching standard
procedures of making smears; (4) in addition to self-education, two courses were held for the technicians and gynecology
residents;(5) providing information sheet of Pap smear preparation; (6) incorporating patients’ records to their HIS records;
(7) informing patients by phone if the quality of Pap smears showing “insufficient cells” and arranging them to repeat the
test.
Results:
(1) The revised standard operation procedures are followed by every technician and physician.
(2) The rate of adherence to standard procedures of making smears is 100%.
(3) The mean rate of “inadequate for interpretation” in the year before implementation of improvement methods was
6.38% (range 5.83%-7.19%) and 5.21% (range 4.86%-5.58%) in the follow-up nine months after launching the
changes.
(4) The amount of paper used for recording decreased from 1,800-2,000 pieces to less than 100 pieces.
Conclusions:
The process and quality of Pap smear tests can be improved by cross-sectoral cooperation. Education to patients,
technicians and physicians is a key factor for improvement.
0649
The Influence of Service Innovation and Organizational Performance on Knowledge Management in a Nursing
Section
Hsu Su-Chen, Wang Yu-Rung, Chiang Hui-Ying
Chi Mei Medical Center, Tainan City, Taiwan
Objective:
The purpose of this study was to examine the relationship between knowledge management, organizational performance
and service innovation strategy among nursing administrators in Taiwan.
Methods:
The investigation was conducted through the cross-sectional study. A total of 265 questionnaires were self-administered
questionnaire in nursing administrators such as team leader, head nurse and department supervisor. Two hundred and
forty-two valid questionnaires were collected, representing a 91% valid response rate. The study instruments included
demographic variables and knowledge management (KM), service innovation strategy (SIS) and organizational
performance (OP) questionnaires. Those questionnaires had satisfactory reliabilities of Cronbach’s alpha above 0.96. The
68- item KM, SIS and OP questionnaires were 1 to 5 Likert’s scale with 1 mean “completely disagree” and 5 meaning
“completely agree”. The higher the scores, the more positive knowledge management competency the participant has.
Valid questionnaires (N=242) were processed through descriptive statistics, item analysis, factor analysis and reliability
analysis. Next, Stepwise Multiple Regression was conducted to investigate the influence of knowledge management
ability on service Innovation and organizational performance.
Results:
The demographic data showed that the subjects were aged 30-40 years (38.4%), university educated (45.9%) and had
the tenure of present work of more than 10 years (56.2%). The nursing administrators had higher consent degree for KM
(mean=3.88, SD= 2.74 ), SIS(mean=3.98, SD= 2.63 ) and OP(mean=3.95, SD= 2.42 ). There was a significant correlation
between the KM and the SIS (r= 0.67, p<.001), KM and the OP(r= 0.74, p<.001). In SIS and KM, the subscale showed
significant correlation between the knowledge acquisition(r= 0.52, p<.001), knowledge storage(r= 0.51, p<.001),
knowledge sharing(r= 0.55, p<.001), knowledge application(r= 0.57, p<.001), knowledge creation(r= 0.65, p<.001).
Multiple regression analysis showed knowledge sharing, knowledge creation and knowledge acquisition explaining 56%
of the variance. In OP and KM, the subscale showed significant correlation between the knowledge acquisition(r= 0.61,
p<.001), knowledge storage(r= 0.58, p<.001), knowledge sharing(r= 0.67, p<.001), knowledge application(r= 0.61,
p<.001), knowledge creation(r= 0.64, p<.001). Multiple regression analysis showed knowledge creation, knowledge
sharing and knowledge acquisition explaining 47% of the variance.
Conclusions:
The nursing administrators who obtain knowledge management capability have better service innovation strategy and
organizational performance. This effect receiving from the knowledge management capability are mainly through
knowledge creation, knowledge sharing and knowledge acquisition.
0652
RCA to Decrease the Incidence Rate of Leaving an Acupuncture Needle on the Patient’s Body in Chinese
Medicine Clinic
Sheuh-Mei Dang, Chin- Hui Chan, Chin-Hsiang Chou, Wen-Long Hu
Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
Objective:
Acupuncture is the most common therapy in traditional Chinese medicine, while leaving an acupuncture needle on the
patient’s body after the Chinese medicine treatment is the most often abnormal event. The statistical rate of leaving a
needle on the patient’s body was 0.49% from 2010.01.01 to 2010.06.30. We use the concept of RCA and the Safe
Practices for Better Health Care -THE NATIONAL QUALITY FORUM of United States, to find the basic factors and the
reasons for the mistaken performance, in order to enhance communication and message delivery between nurses and
physicians to provide the necessary special equipment and care process improvement, and to reduce the incidence of
leaving an acupuncture needle on the patient’s body in Chinese medicine clinic.
Methods:
The remote causes of leaving an acupuncture needle on the patient’s body included: physicians did not count the number
of needles or calculated wrong; physicians did not mark or remind the acupuncture point of hidden part; the low nursing
knowledge of acupuncture point; nurses were interfered during taking the needles, and the lack of appropriate needle
container. The proximal causes were the patient didn’t want to remove the clothes, and nurses did not take off all the
needles. Improvement measures in accordance with the reasons were the monitoring of incidence of mistake rate and
accuracy of physicians counting of the number of acupuncture needles, the development of communication and message
delivery between nurses and physicians, the improvement of the processes while the number of needles was wrong, to
add marks of the needles on hidden parts, to held education courses of acupuncture points , to make clinical manual for
acupuncture department nurses, to provide transparent needle container, warmth infrared light, and the equipment for
covering private parts and other measures.
Results:
Four months after implementation of the program, the incidence rate of leaving needle was decreased from 0.49% to
0.2% (the rate of physicians not counting the number of needles decreased from 26.8% to 3.1%, calculated error from
22.3% to 4.2%, the rate of acupuncture point awareness of clinical nurses enhanced from 81.8% to 98.7%).
Conclusion:
After implementation of the case, it did reduce the incidence of leaving an acupuncture needle on the patient’s body in
Chinese medicine clinic. To find the root causes and analysis the measurements helped us to find out the causes to make
improvement, and to enhance the quality of patient safety and satisfaction (from 89.7% to 96.4%). We hope to promote
the results to the traditional Chinese medicine ward, and to pursue high quality traditional Chinese medical care.
0653
Value, Validity, Consistency: The Senior Medical Officer Performance Review.
Richard Ashby, Kim Harris, Michelle Winning
Princess Alexandra Hospital, Queensland, Australia
Objective:
To establish value, validity and consistency of the Senior Medical Officer Performance Review.
Methods:
The Senior Medical Performance Review was developed and implemented three years ago at a major tertiary hospital in
Brisbane, Australia. It continues to be the only consultant performance review tool which examines individual clinical
outcomes, annual development activities and team and peer review outcomes.
Clinical outcomes reviewed are defined by each specialty and may include review of average length of stay, mortality
rates (adjusted), complication rates and infection rates against peers, the organisation, the state and where relevant,
nationally.
Discussions regarding annual development activities are focused on individual learning needs and goals and are also
aligned with organisational strategy.
A significant and defining component of the process is an anonymous peer review in which multisource feedback
regarding individual senior medical officers is sought from colleagues, directors and team members (including registrars
and senior nursing staff). The review domains are aligned with the CANMED competencies and the Australian Medical
Council’s Good Medical Practice.
With over 450 consultants having undergone the three yearly SMPR process, methods have been applied to determine
the value, validity and consistency of the outcomes.
Results:
Value: Individual Clinician Value:
Formal evaluation demonstrating that;

The majority of respondents agreed that the process was meaningful.

More than half of the respondents agreed that the SMPR produced valid information

68% of respondents agreed feedback they received from the review process would inform their
practice.
Organisational and personal/professional value:
Validity:

Identification of a small group of clinicians who scored statistically significant lesser outcomes than
peers at the 99% confidence level.

Identification of significant communication and teamwork concerns requiring 3 party involvement.
rd
Concurrent validity with the peer review period matching the outcome measures period.
Content Validity with the consultants reviewing the peer review tool to ensure specialty specificity, high
return rate.
Face validity with a high level of acceptance; 72% of clinicians cannot think of a “better way to do it” and
100% participation with no appeals.
Consistency: Internal consistency (applying Cronbach’s Alpha) of peer reviews is at a level >0.9 indicating high level
consistency.
Other Outcomes:

SMPR implemented in 3 Queensland tertiary hospitals, 4 secondary hospitals and Statewide Pathology Services

11172 individual team and peer reviews completed

Statewide workshop to teach the process

Commencement of district wide specialty SMPR which will include in excess of 1500 senior medical officers
Conclusions:
This is the first time a performance review such as the above has been undertaken for Senior Medical Officers in Australia.
The SMPR has strong face validity with clinicians being accepting of the process and outcomes of the review.
A significant outcome of the process has been the willingness and enthusiasm of individual senior clinicians to reflect on
their personal practice, agreement to be assessed by other health care professionals and a desire to discuss career
development and opportunities.
0654
Process engineering (PE) ameliorates performance of a chemotherapy outpatient clinic (CC): A tool for constant
improvement in functioning strategies
1
1
1
2
Jean Latreille , Christine Mimeault , Nathalie Moreau , Mike Gannon
1
2
CICM/hop Charles LeMoyne, Longueuil, QC, Canada, Clinicon inc., Prevost, QC, Canada
Background: Our CC has 16 chemotherapy chairs, 6 chemotherapy nurses and 2 coordinating nurses. Scheduling was
done by reserving time for long (more than 4 hours) treatments (Rx) early in the morning. Short ones were accepted
throughout the day. No in depth planning strategy existed. The number of Rx administered in our CC increased by 25%
over a 4 y period (6,098 in 2006 to 7,633 in 2009). More worrisome was an augmentation of 158% in the number of 4hrs+
Rx, from 478 in 2007 to 1235 in 2009. This increase in workload caused numerous delays, lengthening of workday and a
budget deficit. Due to limited resources, and growing dissatisfaction from our patients (pts) and concerned professionals,
we had to improve the performance of our CC.
Methods: PE documented flow of pts, bottlenecks, CC loading rate and chair occupancy (CO) throughout the day, time to
reach 90% occupancy, number of Rx given, work strategy, overtime, scheduling/appointment procedures and overall
clinic efficiency/treatment capacity.
Results: Analysis revealed that achieving 90% CO took 5.30 hrs. Total capacity utilization was 50%. 71% of pts were
admitted late (mean delay: 48 min). Main bottlenecks were: delayed laboratory results and same-day physician’s
appointments. PE called for (1) a two-day patient flow model with blood tests and physician appointments on Day 1 and
treatment on Day 2, (2) implementation of MedIQ™, a computerized scheduling system built for us by the process
engineer that takes into account treatment length and set-up time, (3) changes in nurse scheduling to facilitate early AM
loading so that 90-100% CO is reached within 90 min after opening, (4) reorganization into 2 pods each consisting of 8
chairs and 3 nurses, (4) acquisition of at least 2 “flex” positions kept-off the scheduling grid to accommodate for delays in
treatment completion (TC) that would affect the admission time of subsequent pts, and (5) 85-90% utilization of capacity
for as long as we had the patient load to fill emptying chairs. Seven months post-implementation analyses revealed high
patient, nurse and physician satisfaction. 90% CO is now reached within 90 minutes as planned. Next day schedule is
finalized by 2 pm the day before Rx. Over this period, we decreased our normal operating hours by one hour and nursing
overtime dropped by 28.2% (262 hrs in 2010 vs 365 hrs in 2009) due to improved planning. Rx increased by 19.5%
(4,425 vs 3,702). Occupancy for same period was 62% of total daily capacity. We are still unable to acquire the flex
capacity required under PE and this continues to cause delays in admissions. After eleven months, decrease in nursing
overtime dropped to 15% and Rxs had increased by 13 %. The decrease in performance on the nursing overtime
indicator was due to overtime caused by delays in TC either due to side effects, addition of unplanned medication by
physician and lack of flex capacity. For the last week of this analysis, delays affected 50% of pts (99/197) and mean delay
to admission was 30 min. This represented a decrease of 30% in the number of pts affected by delays and 37.5% in the
average delay to admission over pre-PE levels. Eventual acquisition of the required flex capacity will allow us to improve
on this. Overall daily occupancy remained at 62% which indicates the capacity to still increase our patient load before we
begin to saturate the extra capacity created by PE.
Conclusion: PE facilitated a major reorganization of operations in the CC and achieved significant improvement in
performance without requiring increases in staff and physical treatment capacity. PE is an ongoing process of continuing
process improvement.
0655
Using Healthcare Failure Mode and Effect Analysis techniques to improve inpatient medication safety
Sheu Hwang-Tzer, Hung Chou-Yuan, Hsiao Lee-Ping, Chen Chieh-Yu
Pingtung Christian Hospital, Ping Tung, Taiwan
Abstract
Computer systems and the software that drives us are used in communicating, prescribing, and medicine, to name a few
applications. Problems created by software bugs or incorrect user administers can range from nuisances to potentially
fatal disasters. The Healthcare Mode and Effect Analysis (HFMEA) can help us to identify problems before they occur, so
they can be eliminated or reduced. When our Inpatient Medication Computer System (IMCS) was completed, we
assembled a multidisciplinary team that included physicians, pharmacists, nurses and IT engineers to graphically describe
the IMCS process and conduct its hazard analysis. Using a Decision Tree, action was taken to eliminate or control risk.
We recalculated the resulting hazard score after the failure modes were reduced or eliminated.
Objective:
All the hazard scores for high risk failure modes were reduced (from 8 or more to 4 or less).
Methods:
The Healthcare Mode and Effect Analysis (HFMEA)
Failure
Mode
Root Cause
Probability
X
Severity
Effect on
Patient
=
Hazard
Take action to
eliminate or reduce
the risk
Results:
We developed and verified the flow diagram for IMCS, but we found the process was very complex. So we identified the
areas of the process to focus on: step2 (electronic medication order transfer to pharmacy package) and step4 (nurse
administers). All sub-processes under both steps were identified, and assigned severity and probability values for each
failure mode. We calculated the hazard score, and prioritized the failure modes for corrective action before and after
completing the action to eliminate or reduce the high risk failure modes. This resulted in more than 60 percent reduction in
the resulting hazard score from the original HFMEA total hazard score for all items. The 11 areas of step2 and step4
addressed were at or below the target of 4 point. Medical team members now consider the IMCS is a useful tool for
medication safe.
Conclusions:
HFMEA was developed as a tool to identify and correct healthcare-safety hazards. This study aimed to identify and
eliminate the potential risks in the inpatient medication procedure that pharmacists use to fill medication orders after which
nurses scan barcodes to confirm the prescription. Using HFMEA we anticipated and eliminated medication safety
problems before they occurred. Consequently, pharmacists and nurses have improved the safety of patient medication.
0656
Evaluating the implementation of an extended infusion Piperacillin-Tazobactam dosing strategy at a large tertiary
care teaching hospital
Rubiya Azmiree, Rehana Jamali, Emily Kao, Bruce Hirsch
North Shore University Hospital, Manhasset, New York, USA
Objective: The objective of this study was to evaluate the implementation of an automatic interchange of PiperacillinTazobactam from a 30 minute-intermittent infusion to a 4 hour-extended infusion dosing strategy.
Methods: Piperacillin-Tazobactam, a broad spectrum β-lactam-β-lactamase inhibitor is widely used at our institution. The
decision to adapt an extended infusion Piperacillin-Tazobactam dosing strategy was based on several factors including
optimizing the pharmacodynamic profile of the drug and reducing the patient’s total drug exposure both of which are
important quality assurance issues. The pharmacodynamic properties of β-lactams identify that optimal bacterial killing is
achieved when time that free drug concentration is maximized above the mean inhibitory concentration (MIC) for the
organism. With this in mind and the results of various studies that show extended infusion dosing is a comparable
alternative to intermittent infusion Piperacillin-Tazobactam, we implemented an automatic interchange strategy to convert
patients receiving intermittent infusion to extended infusion Piperacillin-Tazobactam.
Although extended infusion Piperacillin-Tazobactam dosing was seen in our institution as early as the last quarter of 2007,
hospital-wide implementation required numerous studies and educational series. Because our institution does not yet
operate on a computerized prescriber order entry (CPOE) system additional precautions needed to be taken to ensure
minimal dosing and infusion errors. A multidisciplinary team was consulted to approve the practicality of converting
patients in the hospital to an extended infusion dosing regimen. Pediatric and emergency department patients were
excluded.
In the third quarter of 2009 reports were generated daily to identify patients receiving Piperacillin-Tazobactam. Clinical
Pharmacists began recommending extended infusion Piperacillin-Tazobactam for those patients that were candidates
(patients whose renal function allowed them to receive Piperacillin-Tazobactam at doses of 3.375grams IV Q6H). The
Clinical Pharmacist’s recommendations were widely accepted and patients were followed to ensure infusion pumps were
being appropriately adjusted to reflect the extended infusion dosing strategy. Once it was determined that prescribers,
nurses and other healthcare professionals involved in patient care were comfortable with the extended infusion dosing
strategy, The Medical Board approved an automatic interchange policy which allowed Clinical Pharmacists to
automatically convert patients receiving intermittently infused Piperacillin-Tazobactam to extended infusion dosing and/or
an appropriately adjusted renal dose.
Data was collected on a monthly basis to monitor the utilization of Piperacillin-Tazobactam. Monitoring of the hospitalwide and floor specific antibiograms will be conducted moving forward as it was too early to gauge changes in PiperacillinTazobactam sensitivity data at this time.
Results: At the initiation of the change towards extended infusion dosing of Piperacillin-Tazobactam (third quarter of
2009), 40% of patients were on extended infusion dosing while 60% of patients were on intermittent infusions. By the
fourth quarter of 2010, nearly 90% of patients were on extended infusion dosing while approximately 10% of patients were
on intermittent infusions. The doses of this specific antibiotic exposure decreased by nearly 1,400 doses per month
resulting in both reduced patient exposure to antibiotic and Pharmacy Department expenditures.
Conclusions: A hospital-wide implementation of an extended infusion Piperacillin-Tazobactam dosing strategy was
safely and successfully adapted at a large tertiary care teaching hospital.
0659
High Tech, High Touch: New Cardiac Patient experience from Assessment to Rehabilitation
Camille, Kam Tak HO, Wai Kwong POON, Peter KING
Hong Kong Adventist Hospital, Hong Kong SAR, China
Introduction:
Coronary artery disease (CAD) is the second ranked killer in Hong Kong. Early detection, treatment & rehabilitation is
crucial. As the very first Heart Centre established since 1985 and equipped with cutting edge technology, skillful and
caring staff and using multi-disciplinary to serve their client who potentially and actually suffering from heart problems,
High Tech and High Touch one-stop-service concept adopted since 2007.
Objective:
To review on patient experience from the High Tech and High Touch one-stop-service concept on Heart Protection
High Tech: The project was led by our multi-disciplinary experts team including our Doctors, Cardiovascular Nurses,
Physiotherapists, Dietician and Lifestyle Management Educators and coordinated by Cardiac Liaison Nurse. The patients
can either approach us through our hospital Website or phone call to contact the staff of Heart Centre and state out their
concern of their heart problem, an one stopped booking system will be activated. Our Cardiac Liaison Nurse will perform
initial assessment and make appropriate referral to our Cardiologist or Health Assessment team. Once diagnosed with
heart disease, the patient will be arranged to admit and under our experts’ hand along with the most advanced technology
to fix his/her heart problem; under the care of Our Cardiac Catheterization and Intervention Centre which can accurately
diagnose and facilitate the patient overall management.
High Touch: In the recovery and rehabilitation period, each expert contributed from their own field of expertise as required
to set up a comprehensive cardiac rehabilitation program, Cardiac Liaison and rehabilitation nurse collaborate with the
team to set up individual patient centered cardiac rehab program for each of the individual needs. The team also applied
the concept of “Contract Learning” on the measurements of patient towards treatment compliances and provide the
following outcomes.
Methods:
Twenty-eight participants recruited into this project, who suffered from CAD and had undergone PCI between 2008 and
2009(n=28, male=68%, female=32%, mean age=59.8, SD=±10) All participants underwent 6 to 12 weeks of contract
learning based cardiac rehabilitation program, with telephone or email support and follow-up service. Data was collected
through monitoring of the patients’ heart health knowledge, drug compliance, smoking habits, dietary compliance,
exercise adherence, and blood pressure control.
Results:
For high tech, clients can contact us through telephone and internet to kick off the one stop service from health
assessment to rehabilitation. For high touch, cardiac liaison nurse act as case manager who guide and accompany the
client to walk through heart health journey. The significant improvement evidence was shown in the participants’ pre and
post assessment, regarding to knowledge score, drug compliance (100%), drug knowledge (Z=-6.788, p=0.000), exercise
adherence (96.9%), blood pressure control (pre-test=61.7%; post-test=93.8% SBP<140mmHg), and dietary compliance
(99.2%). However, there was a lesser degree of improvement in smoking cessation (Z=-1.099; p=0.272).
Conclusions:
This project has demonstrated the effectiveness on High Tech High Touch one stop service from Assessment to
Rehabiliation concept to promote Heart Health. It was also favourable perceived by all patients and staff. By using
contract learning approach, we can promote a healthy improvement in lifestyle to the clients, as evidenced by the high
level of adherence to both exercise and dietary regimens, and the high level of patient satisfaction amongst the clients.
Every discipline can use the concept of contract learning to share their knowledge with their clients, and obtain optimal
health-care outcomes. We believe the key to success lies in the concept of partnership between the health-care team,
their patient clients, and the patients’ families, with our cutting edge technology.
0660
Team skills training in health care: when, what & how
Robyn Clay-Williams, Jeffrey Braithwaite
Centre for Clinical Governance Research, Australian Institute of Health Innovation, UNSW, Sydney, NSW, Australia
Objective: This paper presents an organisational training strategy for training team skills in the health professions.
12
Methods: While the importance of team skills to patient safety has been acknowledged for over a decade , the system
for training team skills in health care is frequently haphazard and uncoordinated. Although work generally occurs in teams,
training is usually scheduled in single disciplinary silos, with little account for the practical requirements of interfacing with
other team members. In addition, team training is often a supplementary activity, which is too easily curtailed or cancelled
in favour of clinical activities. Development and implementation of an organisational training strategy for teaching nontechnical skills would assist in meeting the needs of health care workers while respecting the time and resource critical
nature of the health system. Elements of the training strategy should include a training model; personnel resources to
develop, conduct, evaluate and manage training in accordance with the model; and facilities and materiel resources to
conduct and evaluate the training.
Results: Clinicians should be trained in two aspects of team skills. Firstly, health professionals need to be trained in
individual portable team skills that allow them to integrate into teams effectively as they move through the health care
system. Secondly, multidisciplinary work teams need to be trained in the team specific skills necessary to effectively
perform their current roles. There are four main junctures in the career of a health professional when team skill training
should be completed. The organisational team skills training strategy model proposes four levels of training: basic team
skills familiarisation, individual team skills training, team training, and trainer training.
Conclusions: Further research is required to explore the efficacy of this training model, or aspects of it, in training health
care workers in team skills. In addition, there is a need to establish standardised and agreed methods of assessing team
skills, so that health care workers can be certified competent in non-technical as well as technical skills, and employment
and further training managed in accordance with their demonstrated level of competency.
References
1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. A report of the Committee on
Quality of Health Care in America, Institute of Medicine: Washington, DC: National Academy Press, 2000.
2. Donaldson L. An organisation with a memory: report of an expert group on learning from adverse events in the NHS.
London: UK Department of Health, 2000.
Figure 1: Health Care Team Skills Training Model
0662
Pharmacist-conducted Medication Reconciliation with Patient Counseling at Hospital Admission to Improve
Quality of Pharmaceutical Care
Chia-Hao Hu, Chu-Chun Chen, Yu-Fen Huang, Hui-Ping Liu
Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
Objectives:
The objective of this study is to improve quality of pharmaceutical care and evaluate the effect of pharmacist-conducted
medication reconciliation with patient counseling at hospital admission.
Methods:
th
th
This study was undertaken between October 17 and November 18 , 2010 in a local hospital in Taiwan. Patients
who were admitted to Internal Medicine, with age over 65 year, more than two co-morbidities and receiving more
than three regular medications were recruited in this study. On the other hand, the exclusion criteria included
patients with cancer, admitted to the ICU, discharged within 48 hours after admission, or unable to communicate.
First of all, the clinical pharmacists selected suitable patients and collected information of their medical and
medication history by using the Computerized Physician Order Entry (CPOE) system. Then, the patients
recruited in this study were interviewed by clinical pharmacists within 48 hours after admission. Every
discrepancy found by the pharmacists was documented. The unintentional discrepancies were discussed with
the physicians and drug therapy was adjusted accordingly. The primary outcome of this study included the rate
of unintentional discrepancies identified by pharmacists before and after patient counseling and the rate of
unreconciled medications resolved by pharmacists.
Results:
Forty-nine patients were recruited in this study and 129 unreconciled medications were found in thirty-five patients by
clinical pharmacists. The types of discrepancies were included dose, frequency, route, omission, duplication, and
substitution and the most common type of discrepancies was omissions with the rate of 58.7%. On the other hand, the
rate of unintentional discrepancies identified by pharmacist which may cause harm increased from 6.6% to 12.4% after
patients counseling and 81.3% of unintentional discrepancies was adjusted after pharmacist intervention. Additionally,
allergy history was established in 16.3% of patients after patients counseling.
Conclusions:
Medication reconciliation is the process of obtaining and maintaining a complete and accurate list of the current
medication therapy of a patient across healthcare setting. The combination of recorded (assessed through the use of
medication records) and reported (assessed through patient counseling) medication use may increase the accuracy of
medication reconciliation process. In our study, executing medication reconciliation with patient counseling by
pharmacists identified and solved drug-related problem. In addition, more complete and accurate of allergy history was
established. Therefore, pharmacist-conducted medication reconciliation with patient counseling can improve quality of
pharmaceutical care. Moreover, this study was carried out in patients admitted to Internal Medicine during one month
period. Implementation of medication reconciliation with patient counseling to further patients, such as surgical patients
may be considered.
0664
Incidence of pressure ulcer at operating theatre in an acute regional hospital in Hong Kong.
Jodie Kwong, Gloria Aboo, Nora Kwok
PYNEH-HA, Hong Kong
Objective:
To identify the incidence of acquired intra-operate pressure ulcer.
Methods:
Patients were prepared and on pressure re-distribution devices according to department’s positioning guideline prior to
operation. Skin assessment was performed on patients to identify any pre-existing pressure ulcer before undergoing
general anaesthesia (GA) for operation. (1) Patients’ skin were reassessed again before leaving the operating theatre (OT)
to identify any pressure ulcer developed during GA. (2) If ward noticed patient develop any pressure ulcer within 72 hours
after leaving operating theatre, ward nurse would inform operating theatre nurse for the pressure ulcer development. The
information of pressure ulcer was recorded onto the Skin Assessment Chart (SAC) and analysed by using the descriptive
analysis.
Results:
During June to December 2010, 3717 patients had undergone GA for operations in the hospital. In which, 16 patients
acquired pressure ulcer intra-operatively. The mean age was 55 (range age 27 - 90). 10(62.5%) were female and
6(37.5%) were male. 14(87.5%) underwent elective and 2(12.5%) with emergency operations.14(87.5%) noticed had
pressure ulcer developed before leaving OT. 2(12.5%) patients found to have pressure ulcer developed following the
operation and reported by wards. The incidence rate of pressure ulcer in operating theatre was 0.43%. 7(43.8%) patients
acquired stage I pressure ulcer. 7(43.8%) patients acquired stage II pressure ulcers. 2(12.5%) patients developed both
stage I and II pressure ulcer. Out of these 16 patients, 7(43.8%) were Orthopaedics patients, 5(31.2%) were from
neurosurgery, 2(12.5%) were from Surgery, ENT and gynaecology specialities each had 1(6.25%) patient acquired
pressure ulcer in operation. Only one patient (6.2%) with operation hour less than three hours; and 15(93.8%) patients
with mean operation time of three hours (range 2 to 12 hours). Eleven patients (68.8%) put on prone position which
contributed to the highest incidence of pressure ulcer. Followed by supine (3, 18.8%), lateral (1, 6.3%) and lithotomy (1,
6.3%) positions. The commonest sites of pressure ulcer were chest wall (8, 50.0%), face and forehead (8, 50.0%), and
iliac crest (3, 18.8%). 9(56.3%) patients were single body area acquired pressure ulcer and 7(43.8%) were multi-body
areas acquired.
Conclusion:
Limited data and information on pressure ulcer acquired in operating theatre has been reported in Hong Kong. This study
serves as the first systematic review and fundamental information of pressure ulcer in operating theatre. From this
preliminary information, it is noted that patients with operation more than three hours and put in prone position were of the
greatest risk in acquiring pressure ulcer at the chest wall, face and forehead during operation. The prevention of pressure
ulcer intra-operatively can avoid prolonged hospital stay due to its complication, delay patient from hospital discharge,
admission and re-admission; increase mortality of certain patient and healthcare cost. Since this study only provides
fundamental information, it is suggested to have a more diverse sample for generalisation. With the information,
standardised pressure ulcer preventive measures can be tailor-made to the operating theatre. To facilitate data analysis,
an incident reporting system to collect information in operating theatre can be considered.
0665
Legislated Health Care Standards: Changes after Three Years of a Regulatory Process - Self Assessed
Compliance, Monitoring Capability, Quality Improvement Activities
Matt Vance, Alyson Ross, Andrew Lockhart, Carli Rowlands
Health Quality and Complaints Commission, Brisbane, Qld, Australia
Objective:
What has been the impact of three years of mandated health care standards by an independent regulator with a
role in managing complaints and monitoring standards? This paper discusses findings from measurement of
acute and day hospital performance against the regulated standards across the first three years of
implementation - July 2007 to June 2010.
Method:
The standards came into effect on 1 July 2007 and were established in accordance with legislated requirements
for health service providers to implement reasonable processes for improving quality. Standards included the
review of hospital-related deaths, management of acute myocardial infarction (AMI) on discharge, complaints
management, credentialing, hand hygiene, prevention of venous thromboembolism (VTE), surgical antibiotic
prophylaxis and correct site surgery.
More than 220 acute hospitals (public and private) and day hospitals have reported regularly on their level of
compliance for three years. Three types of data are considered in this paper:
• Self assessed compliance
• Capability to monitor - quantitative data provision (process and outcome indicators)
• Quality improvement activities (qualitative data)
Changes across all hospitals were considered over the three years to 30 June 2010. Differences among provider
types in terms of self assessed compliance and capacity to provide quantitative data were also explored.
Results:
Self assessed compliance
Self assessment of compliance with the key principles underlying the standards improved across all standards
from the baseline level. The credentialing standard moved the least, with a 10 percentage point shift in the
number of compliant hospitals, while the review of hospital-related deaths moved the most, with a percentage
point shift of more than 55.
Capability to monitor
Since implementation, there has been strong improvement in the capability of hospitals to collect data and self
monitor standards. For all except two standards (AMI and VTE prevention) hospitals now exceed 90% in terms of
capability to monitor. The size and quality of sampling for audits also improved over the three years.
Quality improvement activities (QIA)
More than 6500 QIAs were submitted in the three year period. Key themes have been analysed and compared
over time. The majority of QIAs involved policy/process development (71%), audit/data collection (55%) and
education strategies (33%). Over the three years the relative proportion declined for these activity types, however
management/governance activities increased from 18% to 34%.
Conclusions:
Hospitals self assessed compliance and capability to provide process and outcome data have improved markedly
since implementation. Differences among provider groups are being pursued in ongoing quality improvement
activities, with a responsive regulation model to target emerging issues from both standards and complaints
information.
0667
Patient safety compromised by failure to follow-up of test results: a review of the evidence for ambulatory
patients.
Joanne Callen, Andrew Georgiou, Julie Li, Johanna Westbrook
The University of New South Wales, Sydney, NSW, Australia
Objective: To systematically review evidence quantifying the extent of failure to follow-up test results for ambulatory
patients and the impact on patient outcomes.
Methods: The authors systematically searched Medline, CINAHL, Embase, Inspec and the Cochrane Database from
1995 to November 2010 for English language articles which quantified the proportion of diagnostic tests not followed-up.
Included were studies which quantified the extent of failure to follow-up laboratory and radiology tests for outpatients,
patients from academic medical centres and community health centres, and patients attending family practices. Failure to
follow up was defined as neglecting to document a follow-up of test results by the ordering physician or another provider.
Studies reporting physician or patients’ perceived rates of failure and studies which measured time to treatment were
excluded. Four reviewers independently reviewed articles for inclusion.
Results: Nineteen studies met the inclusion criteria: all were conducted in the United States. The majority of study
designs used retrospective medical record reviews (n=15) to provide documentary evidence of test follow-up. Most
studies included lack of follow up for abnormal laboratory tests (n=13) with potentially life threatening outcomes if missed:
including serum potassium, thyroid stimulating hormone (TSH), international normalised ratio (INR), prostate-specific
antigen (PSA) and glucose testing for diabetes. Eight studies examined missed abnormal radiology including
1
mammograms. There was wide variation in lack of follow-up of abnormal laboratory results: 2.3% (abnormal TSH) to
2
3
4
66.97% (abnormal glucose). The two studies on mammogram follow-up reported 11% (9/82) and 35.7% (45/126) of
abnormal mammograms with no documented evidence of patient follow-up. Lack of follow-up for other radiology ranged
5
6
from 2% to 22.9% of images. Those studies which examined impact on patient outcomes included missed cancer
diagnoses particularly missed breast and colorectal cancers. Work practices used by clinicians to follow-up tests varied
between individuals and practice settings. Information systems used to track and document follow-up varied between
complete paper-based or electronic systems to a combination of manual and electronic records. One study showed the
use of a partial electronic medical record (paper based progress notes and electronic tests or vice versa) was associated
with higher follow-up failure rates compared to not having an electronic medical record (OR 1.92; P=.03) or having an
7
electronic record that included both progress notes and test results (OR 2.37; P=.007). It was also reported that
documentation of follow-up by the treating doctor was associated with appropriate follow-up of results (OR 2.79; 95% CI;
4
1.11 to 6.98; P=.029).
Conclusions: Failure to follow-up test results is relatively common in the ambulatory setting and can have severe
consequences for patients and expose clinicians to malpractice liability. There are risks to patient safety given the
complexity of the test management process, reliance on clinicians’ memory and use of outdated manual information
systems. Strategies suggested for reducing the problem include: electronic alerts to clinicians combined with electronic
documentation of receipt and follow-up action; patients’ accessing test results directly; electronic audit capability to
feedback missed results to physicians; and site specific policies regarding who is responsible for taking action on
abnormal results. The test management process has multiple components and includes different groups exchanging
information across various settings. Information technology has the potential to improve this process ensuring timely
communication of results to patients and between all members of the health care team.
References: 1. Schiff et al. Arch Int Med. 2005;165:574-577. 2. Kern et al. BMC Hlth Serv Res 2006;6:1-6. 3. Chen et
al. J Nat Med Assoc 2010;102:720-725. 4. Poon et al. J Gen Intern Med 2004;19:316-323. 5. Choksi et al. AJR
2006;186:933-936. 6. Cram et al. J Qual Pt Saf 2005;31:9097. 7. Casalino et al. Arch Intern Med 2009;169:1123-1129.
0668
Risk Indicator for Hospitals: Legislated Health Care Standards and Complaints to an Independent Regulator
Michael Ward, Matt Vance, Alyson Ross, Carli Rowlands
Health Quality and Complaints Commission, Brisbane, Qld, Australia
Objective:
Can regulated standards and health care complaints be used as a combined risk indicator for hospitals?
Method:
An independent regulator with a role in managing complaints and monitoring standards to protect the health and
wellbeing of consumers of health services has combined these functions to assess the usefulness as an indicator
of risk. This paper discusses findings from measurement of performance of health service providers in
Queensland against the regulated standards post implementation.
The standards came into effect on 1 July 2007, established in accordance with legislated requirements in
Queensland for health service providers to implement reasonable processes for improving the quality of their
health services.
A study group of 23 public hospitals were selected based on a minimum number of separations for each period
and availability of continuous data. Data assessed for this paper included:
Ø
Self assessed compliance:
Self assessment of compliance with the key principle criteria underlying the standards. This was
grouped at the hospital level for three years
Ø
Complaints received:
Complaints received by the independent regulator were collated at a hospital level.
The study looked at correlations between standards compliance and rate of complaints within each year
period. The differences among hospital sizes and types were also considered.
Results:
Limited correlations were found in the full set of hospitals. When the hospitals were grouped based on separation
volume, patterns emerged whereby medium and large hospitals showed low correlation in the early stages of
implementation, leading to moderate correlations in the middle year and returning to low correlations in the third
year. This may indicate that there is a learning organisation phase that could be followed, however once
standards are well established in the organisation they begin to lose any value as overall indicators of complaints
and would also lose value for a combined quality indicator. Qualitative information provides some insights into the
reasons for such differences.
Conclusions:
Self assessed compliance to regulated standards combined with complaint rates for a hospital may provide a high
level indicator for risk during the implementation phase when there is variation amongst hospitals. A key future
question will be: “What is the nature and quality value of the rate of complaints received by an external regulator?”
Further detailed analysis and collaboration through a responsive regulation model with corporate and clinical
governance groups is required.
0672
Australian baby boomers’ perceptions of quality of health care
Claire Brown, Lawrence Lim
Griffith University, Queensland, Australia
Objective:
The study identifies the perceptions of the meaning of “quality” of health care by older Australians.
Introduction:
The first “Baby Boomers” are reaching retirement age. They have being described as better educated and wealthier than
previous generations (Quine & Carter, 2006). They are also more assertive about their preferences in regards to their
health needs and how these needs are fulfilled. As use of health services increases with age, and combined with
demographic aging the use of health services must increase exponentially, it is important to know the expectations of
older people regarding quality of health care.
Method:
This study is designed as a qualitative inquiry focusing on older Australians’ perception of quality of health care. Initially, a
review of the literature was conducted. The views of older Australians was sought in focus groups either in Senior
Citizens’ Centres or in assisted living facilities. These audio-recorded interviews involved semi-structured open-ended
questions along with trigger questions.
Results:
The following are key results from the study:
•
•
Further evidence that older people will continue to demand more from health care providers,
Maintaining independence is a significant factor in older peoples’ perception of quality of health
care; there is further confirmation that they wish to stay on their own leading to downsizing and
age-friendly housing considerations.
Implications:
The results of this study would have implications for the aging baby boomers, their families and carers, healthcare
professionals, and policy makers:
•
•
Retiring baby boomers will have a significant impact on what age-friendly houses really entails;
nursing homes will have to consider how they are designed and managed to become more like
homes,
If maintaining independence is such a key feature in the views of the elderly, significant
changes need to be made to the ways in which health care is envisaged in order to provide the
technology required to enable older people to live at home independently (as is the case in
Spain).
Reference
Quine, S, & Carter, S. (2006). Australian baby boomers’ expectations and plans for their old age. Australasian Journal of
Ageing, 25(1), 3-8.
0673
Measuring Patient Outcomes to Improve Care – Is the Circle Complete?
Jen Bichel-Findlay, Chris Maxwell, Linda O'Connor, Anne McIntosh
Australian Council on Healthcare Standards, Sydney, NSW, Australia
OBJECTIVE:
To evaluate the integration of clinical indicator results into local healthcare service delivery.
METHODS:
Since 1993, the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program (CIP) has been the
largest source of data collected nationally with the intent to measure the quality of health care delivery in Australia. Over
670 healthcare organisations (HCOs) submit data to the CIP. An extensive evaluation of the program focusing on user
satisfaction was undertaken in late 2010. This presentation will focus on the results across five fixed statements
addressing the integration of the results into healthcare delivery. Over 300 responses (n=321) using a five-point Likert
scale were received from three pre-identified groups of users - existing CIP members, CIP working party (WP) members,
and health professional colleges (HPC) who support the CIP. Strongly agree and agree responses to the fixed statements
were summed and provided as a percentage. Pearson’s chi-square probabilities were used to determine statistical
significance. Representatives of the HPCs were asked how the results should be used by HCOs, whereas existing CIP
and WP members were asked how the data is used in their organisations.
RESULTS:
The HPC representatives rated all five statements higher than the WP and CIP members. Whilst 56% of HPC
respondents viewed clinical indicator results as central to how a HCO evaluates its services, only 47% of CIP members
and 34% of WP members indicated this view was evident at their employing HCOs. Additionally, 71% of HPC
respondents regarded indicator results as providing accountability for the services offered by the HCO, whereas only 60%
of CIP members and 50% of WP members supported this statement.
Over two thirds of HPC respondents agreed that HCOs should view indicator results as important in informing consumers
of the services it provides, yet only one third in the remaining two groups agreed that this view was demonstrated by their
HCO, and this was statistically significant (p<0.05). A large majority of HPC respondents considered that the indicator
results should be provided to the relevant clinical speciality chairs and directors (94%) and should be used to stimulate
research activities and quality improvement projects (85%). The reality revealed by responses from the other two groups
suggests that chairs and directors may not receive the indicator results (64% do) and results lead less frequently to further
investigation (42%). The difference between the groups for these statements were also statistically significant (p<0.05).
CONCLUSIONS:
HCOs are increasingly reporting clinical indicator data, yet integration with the clinical sources of this data is often
incomplete. Results that are not communicated back to the relevant clinicians are unlikely to drive action. HPC
representatives clearly acknowledge the link between indicators and improvement in the delivery of care, however CIP
and WP members may not see the same level of support within the HCO. The burden of data collection can only be offset if the results are used to change practice to improve patient experiences or outcomes. Strategies are needed to assist
HCOs to recognise that their CIP results must be distributed to the appropriate clinicians and that all relevant HCO
personnel can interpret the results and understand their significance to clinical practice. Through this, the potential
changes to practice to improve patient outcomes can be investigated and supported. An education program is currently
being developed to reinforce the criticality of results dissemination and integration with healthcare delivery.
0676
PAPER-LESS Project: Medical Record Forms Management System
Stewart Wong, Chi Wai Cheng, Hon Wah Leung, Oliver Chan
Hospital Authority Castle Peak Hospital, Hong Kong
The Castle Peak Hospital (CPH) is the oldest psychiatric hospital in Hong Kong with about 1,100 beds. Numerous forms
in different versions and formats were in use in the hospital. This inconsistency had negatively affected the efficiency at
work. Furthermore, a significant number of cabinets were used for the storage of forms in ward area. These cabinets were
space occupying and had obstructed the view from the nurse station to the patient areas.
Aim & Objectives
The hospital management aimed to achieve a green hospital environment. One of the approaches was to minimize the
number of printed forms in the hospital. Since the early 2010, a project team has been formed to convert the forms into an
electronic database, and to develop a computer-user interface (software program) with the following features:
a. all the relevant forms could be retrieved by using a single click
b. a fail-secure feature to ensure only the latest version of the form could be used by the staff
c.
a preview function to eliminate the unnecessary wasting time for loading relevant software before printing.
Methods
The Project Team began with a comprehensive stock-taking and sorting of all forms in use in the hospital. Two pilot
wards were identified and opinions solicited from the ward staff. A preliminary design by brainstorming for an appropriate
software interface was made and a prototype program was developed. The prototype program was put on trial in the two
pilot wards and feedbacks were collected from the end-users. Further enhancements were made to the program and a
Phase I Program was put into live run in the pilot wards. Efforts were also paid at the same time to redesign and uniform
all the forms. Stage II pilot would be in two clinical departments of the Hospital, involving 10 wards starting from March
2011.
Results
There were more than 300 medical record forms identified in the initial stage. Since January 2011, over 190 forms have
been digitalized and there was no outdated form in the ward. An average of 0.65 square meter of space was created in
each ward due to the successful removal of 4 to 5 cabinets and at least 5 piles (2500 sheets) of papers. Time spent on
stock-taking and ordering has been reduced by 46%.
Conclusion
The effort paid by the project team was most rewarding. Successful elimination of outdated and irregular forms would
mean the records of our clients are kept in an organized and commonly accepted template. This is in line with the quality
improvement standards promulgated by the Hospital Authority (2008) and the accreditation standards (The Australian
Council on Healthcare Standards, 2010). Standardization would facilitate the capture of clients’ care data and input to the
computerized health information system. The objectives of the project were well-achieved. The project is an initial step
contributing to a larger Health Records Management System. There were additional benefits of saving ward space and
time, and contributing to the environment.
Reference
Hospital Authority. (2008). Quality improvement standards for hospitals.
The Australian Council on Health Care Standards. (2010). The ACHS EQuIP 4 Hong Kong Guide.
0679
A Pilot Study on the effect of a modified Sedation Management Protocol on Weaning of Mechanical Ventilation
Wai Han, Jenny Law, Wing Yiu, George Ng, Ki Fung, Vincent Mok, Wing Fai Tsang
Ventilator Ward, Queen Elizabeth Hospital, Hong Kong
Objective:
To examine the effects of nurse-implemented modified sedation management protocol on weaning of mechanical
ventilation in ventilator ward.
Methods:
Setting: Queen Elizabeth Hospital is a 1,800 beds regional hospital under Hospital Authority in Hong Kong. Majority of the
patients received mechanical ventilation are cared in ICU/HDU. Ventilator Ward was established in 2002 which provides
16 beds for the patients that received mechanical ventilation (MV) but cannot be admitted to ICU/HDU due to issue of bed
occupancy and triage criteria.
st
th
Study Design: A Pilot Study with quasi-experiment method was used. From 1 October 2010 to 5 January 2011, 29
patients fulfilled the inclusion criteria for the study and were recruited. Main outcome measures of the study include
mechanical ventilator days in the ventilator ward, rate of successful extubation, incident rate of unplanned extubation and
in-hospital mortality.
Instruments: The modified management protocol is a package of nurse-implemented protocols which include (i)
Alogorithm-based sedation protocol; (ii) Daily awakening protocol, and (iii) Spontaneous breathing trial protocol. As from
October 2010, the goal-directed sedation and daily awakening protocols have been used in the ventilator ward to
supplement the existing weaning protocol for MV. This package of protocols serves to minimize patient distress related to
use of MV, optimize use of sedation and increase readiness for assessment of extubation.
Result:
The mean age of the interventional group and the conventional group are 75.6 and 74.7 respectively (p = 0.77; NS). The
compliance rate of filling up the form among the completion was 79.4%. For the drop out rate, the interventional group
was 21.6% in compare with the conventional group was 18.9%. Of the interventional group, the mean number of sedation
days was 2.3 days. The mean sedation score was 3.5 which reflected patients in the interventional group were optimally
sedated. The interventional group has a trend of lower mechanical ventilator days compared to the conventional group
(4.80 days vs 5.99 days; p = 0.59). The interventional group has a 14.4% reduction in length of stay in the ventilator ward
compared to the conventional group (5.76 days vs 6.73 days). There is a decreasing trend of having unexpected
extubation rate after the implementation of the protocol (16.7% in the Conventional group and 10.3% in the interventional
experimental group; p = 0.48). There is no significant difference in the successful rate of weaning of mechanical ventilator
between the interventional group and the conventional group (65.5% vs 67.9%). There is also no mortality difference
between the interventional group and the conventional group (34.8% vs 32.1%). The mean time between the cessation of
sedation to time of successful extubation was 2.72 hours.
Conclusion:
The implementation of nurse-driven modified sedation management protocol may reduce duration of MV and length of
stay in ventilator ward. The protocol helps to deliver appropriate sedation to patients undergoing MV and improve patient
comfort. The protocol may improve patient safety by minimizing unexpected extubation. A large scale interventional study
should be done in the future to consolidate the effectiveness of our modified sedation management protocol. Areas on
doctor/ relative satisfaction to our management protocol, and its effect on rate of ventilator-associated pneumonia should
be further explored.
0684
A Paediatric Unit Dosing Intravenous Admixture Service with Information Technology Support to Strengthen
Medication Safety
Jeffery, Yiu Ming LEUNG, Agnes, Ching Yu CHONG, Wai Fong KO, Kam Ming CHAN, Hin Biu CHAN
United Christian Hospital, Hong Kong
Introduction:
Children are vulnerable to medication errors. The increased need for calculations, dilutions coupled with dosing based on
patient’s body weight, surface area, age and gestational age poses particular challenges to the prescribing, dispensing
and administering of medication. There is a genuine need to establish a mechanism to enhance medication safety. In
2010, Information Technology (IT) Department and Pharmacy collaborated to improve medication safety in neonatal unit
and paediatric intensive care unit (PICU). A specially-designed pharmacy intravenous admixture service (PIVAS)
programme was established. A mistakes-proof solution to one of the errors-prone nursing procedures for the “three
checks and five rights” was implemented.
Objectives
To enhance patient safety in medication administration and to enhance effective use of medication and reduce wastage.
Methodology:
The programme is divided into two phases with the involvement of clinical pharmacy service and information technology
support.
Phase One: Unit doses of medications prepared in Pharmacy with IT support
The Pharmacy Service: The clinical pharmacist verifies prescription, prepares individualized intravenous unit doses in the
pharmacy during office hour from Monday to Friday except holidays.
IT support:
1.
Computerized unit dose drug labels with patient’s particulars, drug name, concentration of drug, drug dosage,
quantity of drugs drawn in the aliquots and expiry date of the unit dose were generated.
2.
Accurate preparation and refilling of unit doses and correct dose timing:

Automatic calculation of volume of drug to be drawn at specific concentration for each unit dose to minimize
calculation errors.

Automatic calculation of expiration dates and time of unit doses to avoid administration of expired drug.

Automatic refill system to ensure right drug administration scheduling (e.g. Q18H)
Phase Two: Enhance safe drug administration with IT support in the neonatal unit
A medication administration record (MAR) 2D barcode label with patient’s particulars, drug name, dose, administration
time, and expiration date of the unit dose is generated.
Handheld devices and dashboard are used for checking drug administration, drug discontinuation, unit dose
administration monitoring, and reporting of drug administration.
Two nurses, after executing the conventional ‘3 checks and 5 rights’, verify electronically by matching the MAR 2D
barcode label, the unit dose drug label and the patient’s particulars on their bracelets. When any error was detected, an
audio and visual alert will be triggered in the handheld device. The checking record will be updated to the dashboard upon
data synchronization.
To discontinue the medication, the doctor select the time of the drug to be discontinued in the handheld device and
synchronize data to the server. The drug will be automatically removed from the PIVAS program and the dashboard,
reducing drug wastage owing to communication delay to the pharmacy. When the drug is due to administer, there will be
audio and visual alarm at the dashboard to prevent dose omission.
Results:
Phase one (13/9/2010 to 23/1/2011), a total of 7640 intravenous unit doses were prepared, no medication error was found.
Phase two (24/1/2011 to 15/2/2011), a total of 1643 intravenous unit doses were prepared. 697 scanned unit doses were
administered for 83 neonates. No medication error was found. 97.4% of the scanned doses were administered on time.
There were 18 (2.6%) delayed unit doses administration because of unavailable intravenous site. The dashboard
displayed 32 (4.6%) reminder when they were due to administer. The electronic verification time using the handheld is
under 10 seconds.
Conclusion
As there is small margin of safety in the Paediatric patients, medication error is potentially detrimental. The programme
outcome is promising as demonstrated in our results. A multidisciplinary team approach to strengthen medication safety
assured safe drug administration.
0686
Developing Radiology Dashboard indicators in order to decrease errors and bring core process improvement in
a teaching hospital in Pakistan
Syed Sohail, Nida Husain, Waseem Mirza, Imrana Masroor, Ahmed Nadeem Abbasi
The Aga Khan University Hospital, Karachi, Pakistan
Objective: Keeping in view the essence behind Quality Management Systems it is imperative that Clinicians and
healthcare administrators interpret enormous amount of data in the course of their work. This is true for assessing the
efficiency, financial performance and monitoring of the quality and safety indicators. These data sets usually reside in
different databases which are generally poorly integrated; development of a dashboard of indicators would lead to better
visualization and assimilation of the massive amounts of data generated in Radiology.
Methods: The Methodology used was the PDCA (Plan, Do, Check & Act) cycle. A cohesive team was developed for
brainstorming, planning, organizing, successful implementation and functioning of a Quality Management System. They
analyzed the performance trends of the past five years; data on managerial, clinical, financial and operational indicators
was collated to have a complete picture of from where we began and where we stand as of today; identifying the key
process indicators for Radiology to project on its dash board. Depending upon the analysis of the past trends, we
reviewed the targets/benchmarks, readjusted targets according to trends/international guidelines, performed validation of
the available data and defined automated processes for extracting information, where applicable.
The team introduced Radiology dashboard indicators based upon recommendations of the Advisory Board and various
regulatory/accreditation bodies (Pakistan Nuclear Regulatory Authority, ISO and JCIA) and departmental needs. The
critical indicators were: compliance to international patient safety goals (JCIA), Personnel Radiation protection Monitoring
(PNRA), Radiology Report Turnaround Time in different modalities, Panic Results, Average Daily Volumes, Average Daily
Revenues, etc. coupled with a few clinical indicators. Each selected indicator required strategies for implementing,
continuous performance monitoring, analyzing & depicting data, implementing change and meeting regulatory
requirements. We have put in place a very comprehensive, highly readable dashboard of key performance, a measure
that has enhanced effectiveness of quality performance monitoring,
Results: Radiology’s Dashboard reliably reports department’s performance to the hospital executives as well as
department staff and faculty. These indicators are used to readily track performance in critical areas and processes and
quickly detect downward trends to trigger appropriate corrective actions. The automated data capturing mechanisms
minimize the risk of misreporting and ensures continuous validation of data sources. It depicts the achieved targets and
reset benchmarks in accordance with the past trends or available international benchmarks.
Conclusion: Departmental indicators are used to readily track performance in critical areas/processes and to quickly
detect downward trends in order to trigger appropriate corrective actions. A Radiology dashboard was developed for
better follow-up and dissemination of the information regarding the performance standards of the department. The
Dashboard reliably reports department’s performance to the hospital executives as well as members of the department.
This dashboard is a powerful tool to communicate departmental performance gaps and help identify and monitor the
effects of quality improvement and patient safety projects.
0687
Control of Linen Loss Upon Discharge Through NEATS to Old Aged Homes
Simon Wong
Queen Elizabeth Hospital, Hospital Authority, Hong Kong
Objective :
To reduce the loss of patient jackets and trousers to old aged homes (OAHs) upon discharge through Non-emergency
Ambulance Transfer Services (NEATS) by 20% in Jan 2011.
Method :
This is a Lean Project following the cycle of DMAIC [Define (D), Measure (M), Analyze(A), Improve (I), Control (C)].
Linen supply is one of ward concerns especially during the surge in admission. Patient jackets and trousers are major
linen items supplied to wards. One way to improve provision is to increase supply. Another way round is to decrease loss.
Sometimes, patients are found dressed up patient jackets and trousers are discharged from wards to OAHs through
NEATS. The project is to control loss of patient jackets and trousers and other dressed up linen items to OAHs upon
discharge from ward through NEATS.
At the Define stage, the Project Charter is used to define the objective as mentioned above.
At the Measure stage, a one-week baseline measurement was conducted on the loss of patient jackets and trousers and
other dressed up items.
At the Analyze stage, no return of linen mechanism from OAHs was identified as root cause for the loss. A new process
was deceived. OAHs could return linen items by making use of the Community Geriatric Assessment Team (CGAT)
vehicle and NEATS ambulances.
At the Improve stage, 39 old aged homes associated with hospital CGAT joined Linen Recycle Scheme. OAHs returned
collected dressed up items after wash. The return quantity was based on self-reporting by OAHs. A 3-tier recognition was
set up, (1)compliment letters to participated OAHs, (2)further commend those actively participated OAHs, (3)Licensing
Office of Residential Care Homes for the Elderly of Social Welfare Department (SWD) was liaised letting SWD know
which OAHs had participated the scheme.
At the Control stage, Linen Recycle Scheme will be launched to OAHs associated with Kowloon Hospital CGAT and
Patient Resource Centre will hold recognition program for OAHs.
Results :
The Linen Recycle Scheme was launched on 6 December 2010. A pilot run of the scheme was conducted for 3 weeks.
The collection results for patient jackets and trousers and other dressed up items against the baseline measurement are
stated in Figure (1).
The collection value was 118% of the projected loss value. The number of Safety Vest and Adult Blue Jackets with higher
value was collected more than expected. It was presumed the OAHs taking the chance returned all those items previously
kept by them. The collection rates for patient jackets and trousers are largely exceeding the target rates of 20%, Figure (2)
9.0%
8.0%
7.0%
Figure 1
8 .5 %
8 .1 %
7 .7 %
6 .4 %
6.0%
5.0%
4 .7 %
4.0%
3 .4 %
3 .1 %
3.0%
2.0%
1 .3 %
1.0%
0.0%
Patient
Jacket
Patient Safety Vest Jacket Bed
Trousers
Adult
Linen Items
Taken Away by
Discharged
Patients
Linen Items
Collected from
OAH
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Figure 2
8.5%
8.1%
7.7%
6.4%
Linen Items Taken Away
by Discharged Patients
Linen Items Collected
from OAH
1.6%
20%
Target
Rate
Patient Jacket
1.7%
20%
Target
Rate
Patient Trousers
Conclusion :
The Linen Recycle Scheme successfully reducing the loss of patient jackets and trousers to OAHs by more than 20%. It is
found that all working units have their own working networks which are related but may work in isolation. If these networks
can be lined up together, they can form a tremendous resource pool to enhance patient services.
0688
The Causes of Medical Error in Malpractice Cases in Taiwan from 2000 to 2009
1
2
2
3
Wei-Lun Liu , Shih-Liang Weng , Chun-Pei Peng , Hao-Hsien Lee
1
2
Department of Critical Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Department of Social Work,
3
Chi Mei Medical Center, Liouying, Tainan, Taiwan, Superintendent's Office, Chi Mei Medical Center, Liouying, Tainan,
Taiwan
Objective: To determine the causes of medical error using court records and to decrease the incidence of medical
malpractice.
Methods: Keywords were used identify cases of medical malpractice, and the content of each case was analyzed to
determine the causes of the medical errors and possible means of prevention. Media clippings were used for background
information, and court records from the Judicial Yuan were pooled for analysis of the medical malpractice cases. The
court records included descriptions by the plaintiff and the defendant, medical identification, expert opinions, and the
verdict rendered by the judges. Only criminal cases from January 2000 to December 2009 were included.
Results: A total of 294 criminal cases were surveyed, and from these the 57 in which the plaintiff was awarded
compensation for medical malpractice were selected for analysis. Of these 57 cases, 42 (73.7%) plaintiffs suffered death,
10 (17.5%) suffered severe injury, and 5 (8.8%) suffered moderate injury. The occurrence of medical error was classified
into four categories: misdiagnosis, improper medical treatment, hospital management, and physician performance.
Misdiagnosis included: 1. incomplete history-taking (5.3%) 2. under- or overestimating the disease severity (29.8%) 3.
incomplete physical examination or laboratory testing (54.4%), mostly due to (a) atypical symptoms/signs (e.g. acute
myocardial infarction with atypical chest pain, subarachnoid hemorrhage without headache) (b) symptoms/signs masked
by drugs or alcohol or (c) failure to inform the attending physician of a patient’s change in condition 4.lack of essential
consultation (12.3%). Issues with hospital management were attributed to: 1. staff errors (9.3%) 2. equipment errors
(7.4%) 4. poor communication (between medical teams) (1.9%) 5. lack of standard operating procedure (25.9%) 6. other
(3.7%). Issues with medical treatment aspect included: 1. operation (46.3%), including preoperative informed consent,
postoperative care and vital signs monitoring, and complications 2. improper medical therapy (33.3%) 3. medication error
(13.0%). Improper physician responses were due to: 1. inexperience (17.6%) 2. incomplete differential diagnosis (12.9%)
3. incomplete treatment planning (11.8%) 4.incomplete medical records (11.8%) 5. symptomatic treatment only (10.6%) 6.
poor communication (with patient, between medical teams or hospitals) (10.6%) 7. continuing the same procedures under
improper circumstances (4.7%) 8. burnout (3.5%) 9. no regular follow-up (3.5%).
Conclusions: Health care is a complex process, and the court records were used to determine the causes of medical
malpractice. Physicians should perform a thorough differential diagnosis, essential consultations, and complete treatment
planning if patients are unstable and/or responding poorly to therapy. If the physician cannot handle the patient, she or he
should seek a second opinion. In addition, the team resource management can be used to improve communication
between medical teams. Through these efforts, we can reduce medical malpractice, promote the healthcare system, and
improve patient safety.
0689
Strategies to Increase Hospital Bed Turnover – An Example of Improvement of Inpatient Bed Transfer
Hsiao Su‐ Chiu
Chi Mei Medical Center, Yung Kang City, Tainan County,Taiwan
Purpose
The aim of this study is to manage an efficient hospital bed allocation and usage, reduce the length of waiting time for
patients, avoid patient complaints and medical errors, streamline the processes, reduce manpower, and increase
hospital revenue.
Methods
Data were collected and analyzed by an integral multidisciplinary team on a regular basis to identify problems and
develop feasible solutions
(A) Problems Identified:
1. There was a lack of unified management of bed allocation; electronic bed allocation system was inconsistent.
2. There were no principles of priority for bed allocation.
3. Nursing staff was not knowledgeable about bed transfer.
4. Nursing consultation system was not implemented uniformly.
5. Uneven distribution as well as unequal supply and demand of resources among divisions.
(B) Responding Solutions:
1. Applying central bed management approach in cooperating with an integrated bed allocation system.
2. Formulating the principle of priority for bed allocation to improve cross-disciplinary care for critically ill patients.
3. Increasing team members’ cognitive awareness and knowledge of bed transfer.
4. Implementing of nursing consultation system.
5. Reconstructing standards of bed distribution and resources applicable to each division.
Results
1. During the project period, a total of six standards/norms were amended and applied.
2. The number of beds transferred was reduced from 1698/month to 1232/month, with the reduction rate being
27.5% (466 cases).
3. Hours of work were reduced by 584 hours/month; time of beds lying idle was shortened by 1048 hours per month.
4. ICU transfer-out within one day elevated from 51% to 90%, with improvement rate of 76.5%.
5. ICU Stay was shortened from an average of 43 hours/bed to 12.5 hours/day, with improvement rate of 70.9%.
6. Number of hospital transfers decreased from 71 people/month to 56 people/month, with improvement rate of
21.1%
7. Analysis of supply and demand of beds of each division was also conducted and completed.
Suggestions
Based on the results of the study, we recommend the following:
1. To assemble a cross-disciplinary, empowered team that is given authority to address demands, look for solutions,
and therefore to deliver efficient management of hospital bed turnover.
2. To evaluate the feasibility of delivering long-term or chronic care services in order to provide patient-centered,
integral health care.
3. To establish external referral mechanism that incorporates and shares medical resources, takes advantage of
excellence across long-term care institutions, and provides the most optimal patient care.
Keywords: hospital bed turnover, inpatient beds, bed transfer
0690
Excellence Beyond Standard Medical Care:- Achieving High Service Efficiency in Medical Report Processing
Through Lean Management Principles
Eddie Siu Lun Chow, Frankie Kay Tai Leung, Cheong Fai Chan, Yun Lan Cheung
New Territories West Cluster, Hospital Authority, Hong Kong
Objective:
Helping 9000 patients every year to face the challenges of diseases associated financial-social-legal issues; a hospital
taskforce was set up to enhance the efficiency of medical report processing by using the Lean management principles.
Methods:
A cross-departmental taskforce, including both administrators and clinicians, was established to study means to enhance
the efficiency of medical report processing. The taskforce involved the Hospital Information and Records Office (HIRO),
Lean facilitators, and the clinical departments of Medicine & Geriatrics (M&G) and Occupational Therapy (OccuT).
The baseline service data in 2009 was evaluated. A detailed study and analysis of the medical report processing workflow
was conducted. Using the DMAIIC model, the taskforce re-engineered the workflow by means of various lean
management strategies including ‘Visual-Stream-Mapping’ (VSM), ‘Visual Management’, ‘Standardization’, ‘Jidoka’, ‘Justin-Time’. Performance was reviewed after implementation of new measures in all the 3 stages of medical report
processing: 1/ Pre-writing preparation, 2/ clinical report writing and 3/ final processing.
Results:
Baseline data in 2009 (from June to December) was collected for the participating departments (M&G and OccuT). There
were a total of 669 medical report applications in the baseline reference period. Twenty-four percent (162 reports)
required a processing time of more than 6 weeks. Lean measures were implemented in mid-May 2010. The results in the
first 5-month were analysed by studying the data of 464 consecutive requests made during that period (325 from M&G
and 139 from OccuT). Comparisons were made with the baseline reference in 2009:In stage 1 (Pre-writing preparation), the proportion of processing time beyond 1 week was reduced by 63.9% (from 29.4%
to 10.6%).
In stage 2 (Clinical report writing), the proportion of processing time beyond 3 weeks was reduced by 91.3% (from 44.8%
to 3.9%).
In stage 3 (Final processing): the proportion of processing time beyond 2 days was reduced by 86.0% (from 9.3% to
1.3%).
Overall, the proportion of medical report with total processing time beyond the benchmark of 6 weeks was reduced by
84.7% (from 24.2% to 3.7%).
Feedbacks from frontline staffs revealed a reduction in workload in addition to improved service efficiency.
Conclusions:
Without an increase in workload, the introduction of lean management strategies resulted in a remarkable enhancement
in medical report processing efficiency across all the stages and in both clinical and administration departments.
0691
National Quality Assessment of Diabetes In Korea
HE Kim, MS Baek, KA Son, KD Lee
HIRA, Seoul, Republic of Korea
Background
Health Insurance Review and Assessment Service (HIRA) is trying to expand the program for evaluating quality for the
patients with diabetes in primary care institutions.
Objective
To assess continuity of care for patients with diabetes in primary health care institutions using the Korea National Health
Insurance claims database.
Method

We selected 790,462 patients who received prescriptions of hypoglycaemic agent in 2008 and those who were
with at least two outpatient visits in 2009.

We examined the ambulatory care visit and adherence to medication as variables to calculate the continuity of care.

Adherence to medication was assessed with the medication possession ratio (MPR) for oral hypoglycaemic
agents.

Continuity level was compared by demographic properties (gender, age, region and income level (type of
insurance)).

We conducted chi-square test for continuity of ambulatory care visit and t-test for medication adherence.
<Formula>
Continuity of ambulatory care visit :
Number of diabetes patients who visited