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MARCH/APRIL 2013 MICA (P) 158/04/2012
at H SG mpus Ca
A newer and better Path
What to expect as SGH Pathology moves into The Academia
The hottest six packs in SGH How do our Occupational Therapists work this out
The watch continues
10 years after SARS, how has the role of Infection Control evolved?
速
the watch continues
10 years after SARS, how has Infection Control evolved?
bench press Trials of a Clinician Scientist
class act
Taking the lead in Transplant education
nursing research
Evidence-based procurement and nursing
03 05 06 08 10 12 14
a newer and better Path
What to expect as SGH Pathology moves into The Academia
circles in the sand MSW Goh Soo Cheng draws life's lessons from sand art
walking the Green Mile
The living landscape on our Campus
in every issue 18 20 22 26 27 28
quality pulse spree in action campus buzz time out your take the last page
contents
LIFE at SGH Campus | Mar/Apr 2013
u foc
s
A newer and better Path
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sers can expect minimal disruption even as our clinical laboratories move into The Academia over several months.
Throughout the move, users will continue to send specimens through the pneumatic tube system. At the receiving end, the Client & Specimen Management (CSM) team will ensure that these are distributed to the correct lab sections. Advisor Tan-Huang Shuo Mei Contributors Podiatry Department, Estee Chan, Geoffrey Gui, Chia Kuok Wei, Ratna Abdul Rahman, Vanessa Peters, Jennifer Wee, Claudia Yeo, Carol Ang, Michelle Scully, Goh Sai Luan Distribution General Services Department, Helen Yang On The Cover Dr Ling Moi Lin, Director of Infection Control. Read about her team’s work on pages 8 – 9. Life@SGH Campus is published every two months in print and online by the SGH Communications Department
“To our end-users, who number almost 6000 on campus, there will be minimal changes in their workflow and at the same time, we will streamline our work processes to make it more efficient and effective.” said A/Prof Agnes Tan, Chairman of the Division of Ambulatory and Clinical Support Services. “The Pathology department has undertaken to ensure that any ‘disruption’ or interim measures are confined to the labs and CSM section as far as possible. We are absorbing all the extra pain and increased work during the relocation, such as packing and moving after office hours and during non-working days, to ensure that services are not interrupted during the move.” We salute our Pathology colleagues for making this service commitment as they juggle the herculean task of relocating and providing "services as usual". The move to the new premises is indeed a milestone, allowing for transformation of services and delivery of improved service standards.
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focus
A newer and better Path (Continued from page3)
Key events & dates
22 April 2013 All specimen* delivery cutover to the Academia Pneumatic tube station addresses 652, 653, 654, 901 Client & Specimen Management (24 hour) Level 8, Diagnostics Tower Tel 6321 3728 No more telelift services @ Blk 6 Level 5 & Blk 9 Level 2 *except Cytology and Histopathology specimens
13 May 2013 Cytology and Histopathology specimen delivery cutover to the Academia Send specimens directly to Histopathology Lab Level 10 Diagnostic Tower Tel 6321 4931
20 July 2013
Opening of The Academia
Who goes where Level 13
TB
12
Virology
BSL3
(TB & Virology)
10
Histopathology
Molecular 11
Bacteriology Immunology
9
Cytology
Haematology Cytogenetics
8
4
Biochemistry/ Haematology/ Client & Specimen Management
7
Pathology Administration
LIFE at SGH Campus | Mar/Apr 2013
up close
Circles in the sand T
he lights go dim. Soothing music starts to play. A woman stands in front of a glass table, makes sweeping gestures with her arms and hands as pictures appear on a wall. Moving in time to the music, they morph from one image into another, constantly changing, almost dancing. Welcome to the magical world of sand art. It was this magical, fluid element which first drew Senior Medical Social Worker Goh Soo Cheng to explore sand art. She first saw it on YouTube. “I felt it was such an unusual, beautiful and non-restrictive art form and the accompanying, soothing music added to the pull.” It piqued her curiosity so much, she volunteered to perform it at her department dinner, despite not having tried it. She wanted to share her experience with her colleagues.
The fine details
Soo Cheng set out on her adventure, learning things by trial and error. She tried different kinds of sand and settled on aquarium sand. It has the coarseness she likes. Besides glass tops, she tried working with acrylic sheets. She practised, watching video clips for tips, tricks and techniques.
All her efforts paid off resulting in a successful performance. She was asked for an encore performance at the Allied Health 10th Anniversary Dinner last year, this time accompanied by vocal music from her Medical Social Services colleagues.
The zen of sand
In school, Soo Cheng enjoyed art and music lessons, leading her to take up the cello in junior college. Now as a working mother of two girls aged two and six, Soo Cheng admits she finds it hard to find free time. When she does, she also enjoys making crafts like 3D miniatures, Christmas items and doing charcoal drawing. The marriage of creating with her hands and the use of music made sand art especially appealing. “The process of doing sand art resembles life. There is no rehearsal, it is a live performance. If you make mistakes, you just move on,” Soo Cheng muses. She adds, “It is easy to pick up and you have to go with the flow and enjoy the process. You can’t be too controlling – it is the nature of sand.”
The workings of sand art •A ll that is required is sand, a glass surface and a creative streak.
• The artist manipulates the sand with various parts of the hands – fingers, palms, knuckles; even arms – into pictures.
• It is much like painting, except
because sand is dry and easy to move, the artist is able to constantly transform one image to the next seamlessly.
• The image is lit from beneath the
glass and an overhead camera projects the images onto a screen or a wall.
• Music is selected to correspond
with the movements and themes.
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focus
Walking the Green Mile W
At about 50 years old, this Angsana tree is the oldest on Campus. Now you know how the café outside the National Cancer Centre got its name.
e troop through the campus every day, our internal GPS locked into our places of work in the buildings on Campus. Along the way, do we ever pause to take in the living landscape painstakingly created and maintained for us? Lee Ewe Choon, Senior Manager of Environmental Services, SGH, who is trained in landscape architecture, walks us through the Green Mile on Campus.
Turning into Third Hospital Avenue, Carpark C is nestled under a natural green canopy, courtesy of several majestic Rain Trees.
Gorgeous Torch Ginger flowers blossom between Bowyer Blocks B and C. Walking around the museum, we come to a little green corner. This peaceful nook is a favourite spot for serious, deep conversations.
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Crossing over to Block 6, one enters a large garden opposite Kopitiam, centred around the ‘Millennium Bird’ sculpture. The lush, enclosed design offers staff and patients a respite, a green Shangri-La.
Next to the retail pharmacy nearby, a vertical garden is the solution to small spaces.
LIFE at SGH Campus | Mar/Apr 2013
“Trees and plants are living creatures, just like you and me. They go through cycles of growth and rest, and experience stress too when conditions are not ideal.” – Lee Ewe Choon, Senior Manager, Environmental Services
GREEN HINTS • There are over 400 trees and
more than 40 species of plants on Campus.
• Landscape design considers
Outside the new Auto-immunology and Rheumatology Centre is Ms Lee’s favourite spot. “The striking, bright red corridor of Red Ginger blooms cheers and motivates me.”
Along College Road, site of the old undergraduate medical school, a majestic boulevard of Rain Trees planted in the 70s evoke an academic grandeur.
human movement patterns, how the features will serve as landmarks and the view from the inside of surrounding buildings, among other factors.
• We get most of our trees from
Malaysia. These plants are ’stressed’ when they arrive and need to ‘recover’ in a nursery before being planted.
• Our Environmental Services
department is supported by three gardeners and a landscape maintenance crew from our service partner.
• Passers-by uproot or cut away Across the road from Block 2, a hole in the roof of the covered walkway accommodates the towering tree – the only Tree-in-One on campus.
Under one such tree, near Duke-NUS, we come across someone who took time to stop and enjoy the shade, wise enough to accept the gift of nature.
flowering shrubs – a reason for non-flowering hedges.
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feature
The watch continues Pages have turned since SARS (Severe Acute Respiratory Syndrome) struck 10 years ago, in March 2003. But lessons learnt the hard way are not forgotten and have been built on. We recount the things we do differently and better in the area of Infection Control, and meet the team that keeps watch for new emerging diseases.
“Infection prevention and control is everyone’s business. Each of us has a part to play and we need to play it well as a team.” – Dr Ling Moi Lin, Director of Infection Control
Key measures
Videos and demonstrations are used to teach correct ways to don Personal Protective Equipment such as masks and gloves.
Mandatory education
Infection Control education at orientation is mandatory for all new employees in SGH. Attendance at these sessions is tracked and the target is that 90% of the new hires are trained within a month of starting work. “We have also creatively built e-learning modules on the principles of Infection Control and use teaching videos on how Personal Protective Equipment is to be worn,” said Dr Ling Moi Ling, Director of Infection Control.
Focus on hand hygiene Hand hygiene as a key practice is now universally recognised as an essential element in every Infection Control programme. At SGH, we Ensuring good hand hygiene practice is key to our Infection Control programme.
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have a vibrant hand hygiene programme and we are recognised by the World Health Organisation as one of the four expert centres worldwide.
Being prepared Emergency preparedness is now part of our Infection Control programme. Through the Infectious Disease Taskforce, SGH has created a firm matrix for precautions to be taken at different scenarios. “We are constantly faced with emerging pathogens but the basic measures of Infection Prevention and Control still apply and work,” said Dr Ling.
Better and more facilities Isolation facilities have increased in numbers and improved in design with the help of funding from the Ministry of Health such as our state-of-the-art isolation rooms in Ward 68 (Infectious Diseases).
LIFE at SGH Campus | Mar/Apr 2013
New risks, new initiatives “With new technologies, there will be new equipment introduced to the clinical areas. These are quickly colonised with bacteria and efforts need to be given to ensure that they can be adequately cleaned so as to reduce the risk of transfer to our patients. The COW (computer on wheels) is an example – Housekeeping now assists in cleaning these daily. “We work closely with the Environmental Services and Facilities departments on keeping the general environment clean. The installation of alcohol seatcleaners in every public and patient toilet this year is an exciting move as we engage users to keep the facility clean,” said Dr Ling.
Members of the watch The hospital’s Infection Control Programme is developed and implemented by the Infection Control Department. Dr Ling leads a team of 10 Infection Control nurses and four administrators. Besides improving patient care, their mission includes supporting staff to minimise occupational hazards related to infections.
The team helps to evaluate new devices such as those that reduce risk of exposure from sharps injury.
Beyond education and training We are probably familiar with the Infection Control team’s work in mask fitting, promoting hand hygiene and educating staff and patients. But do you know that they also:
• Collect, track and analyse data on an on-going basis, on healthcare related and communicable infections, such as those attributable to the multidrug-resistant organisms (MDRO) such as MRSA. The monitoring enables them to detect early clusters and prevent outbreaks.
• C onduct audits on compliance to Isolation
Precautions and Hand Hygiene among staff, as well as check on compliance during renovation and construction.
• G o on regular rounds with Environmental Services department staff and work closely with them to ensure their policies and practices are in keeping with Infection Control requirements.
• C arry out random air sampling at selected areas to monitor fungal spore counts during major construction.
• P articipate in research and quality improvement
projects in order to test or implement best practices.
SARS outbreak 2003 SingHealth 14,682 individuals who stood fast in duty, among whom we remember: Vascular Surgeon Dr Alexandre Chao; and Urology Centre healthcare attendant Mdm Kiew Miyaw Tan Worldwide November 2002 – July 2003 774 deaths The team (from left): Senior Nurse Clinician Lee Lai Chee, Senior Nurse Clinician Tan Kwee Yuen, Senior Staff Nurse Tan Soong Geck, Director Dr Ling Moi Lin, Nurse Clinician Molly How Kue Bien, Senior Staff Nurse Wong Yin Yin, and Senior Staff Nurse Hatijah Tohid.
Singapore March to May 2003 33 deaths
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bench press
Trials of a Clinician Scientist
The boy sc challenges out in Pierce Cho w (left) alw in his strid ays takes e.
His name is synonymous with liver cancer research and he is a familiar figure at the Duke-NUS Graduate Medical School where he is a Professor in the Office of Clinical Sciences. Prof Pierce Chow, who is also a Senior Consultant in the Department of General Surgery at SGH, has more than 170 scientific papers, books and book chapters to his name. He recently capped his long list of awards and accolades with the much coveted National Medical Excellence Award National Outstanding Clinician Scientist Award 2012. The journey to his achievements is sign-posted with trials, and sheds light on the man himself. In the words of the history buff, “the past has so many lessons for the future.” What was it like for you growing up?
I grew up in Kuching, East Malaysia, which was a very small town where you knew almost everybody. It was a place without homework. I went to a very sportsoriented school. Every afternoon we would play games - hockey, rugby - and scouting took up a big part of my life. It was a good childhood.
When did you decide to be a doctor?
I knew I wanted to be a doctor when I was quite young as I was very impressed with General Practitioners. They seemed so kind and knowledgeable, so I wanted to be one when I grew up. Of course, I had no idea then what a specialist was. I just wanted to be like my family doctor.
What made you choose to attend medical school in Singapore?
In my class of 45 students, four went to medical school. I went to St Joseph’s, which is the best school in the state. Some of my classmates who could afford it went
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overseas (to study) but I only got a choice of either Singapore or Malaysia as my family wasn’t well-off. Eventually, I decided on Singapore as I had relatives here.
How did you make it through medical school here?
Financial resources were thin as there were three boys in the family. I worked for a few years before starting medical school at the National University of Singapore in 1984. The school fee then was $1,400 per semester; and with about $3,500 in my pocket, I thought that was enough: “Surely the school won’t kick me out even if I have no money.” I also gave tuition three times a week which was enough for my hostel fees of about $150 per month. That was how I got by until they increased the school fees in my final year to $4,000. I thought I would have to drop out for sure! Fortunately, the Rotaract Club gave me a loan to finish medical school.
LIFE at SGH Campus | Mar/Apr 2013
What got you into research?
I always say that choices in life are shaped by both your interest and the environment. Professor Soo Khee Chee (now Deputy Group CEO of SingHealth and Director of the National Cancer Centre Singapore) played a big role. I had joined Prof Soo at SGH as surgical Registrar. His philosophy is that an institutional surgeon should also be a scientific surgeon because this is how surgery can move forward and improve outcomes. He “encouraged” all Registrars to do research in the subspecialty field they are interested in; and asked me to consider the liver. Besides doing basic research in liver regeneration for my PhD (which he encouraged me to do), he also asked me to do clinical research in hepatocellular carcinoma (HCC) - the most common form of liver cancer. He introduced me to a very good mentor – Prof Machin from the National Medical Research Council, Clinical Trials and Epidemiology Research Unit.
Tell us about the multi-centre trials group which you co-founded in 1997.
After my first 20-patient HCC study, I realised that to run a meaningful trial, we need large numbers of patients. These can be found only through collaboration with other medical centers. That’s how the Asia-Pacific Hepatocellular Carcinoma Trials Group was started. I was only a Registrar when I conducted my first 324-patient multi-centre trial that looked at the practice then of using the drug tamoxifen to treat patients with inoperable HCC. It was an important trial, as it showed that patients on placebos did better and the practice in place then was wrong. As a result, nobody uses
tamoxifen to treat liver cancer anymore. The group has gone on to conduct many other studies and I am currently leading our sixth multi-center trial.
Describe the life of a clinician scientist
It is very taxing and chaotic. The process of research and discovery is not ordered. For example in a clinical trial or in translational research, you start with a set of protocols. But things won’t run like that. There will be problems – logistical or scientific – which you have to solve, and you may have to meet frequently with your collaborators and suggest changes to troubleshoot. You cannot anticipate it. You simply have to be prepared to change direction. It is unlike clinical life which is more predictable, with standard solutions. There are no standard solutions in research. It is constant problemsolving and that is the process of discovery.
How did you manage your multiple roles?
The worst time was when I was a junior surgeon, a Registrar. As I was a full time clinician I could only do my PhD research outside of work hours, on weekends and during annual leave. And because I did this parttime, it took me about seven years to complete my PhD studies. I actually cannot remember my older children growing up. In fact, I cannot remember anything from that period as I was so busy – not even movies, songs, etc. That’s why for my younger children, I tried to pay a little more attention to them.
What qualities should a researcher have?
Interest and aptitude. Besides that, altruism. Most researchers don’t become rich from doing research. In research, there are more failures than success - it is inherent in the game. Institutional support is thus very important.
“We definitely hope that patients will have better outcomes arising from our research because there is no other way to have better outcomes.”
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class act
Taking the lead in Transplant education
Transplantation medicine is one of the most Asst Prof Terence Kee challenging and complex areas of modern medicine. However, it is not covered in great detail in medical education, and most of the learning happens on the job. To address this gap, SingHealth organised a Basic Transplant Course in December 2012, the first in Singapore. We catch up with Asst Professor Terence Kee, the Course Director, and Senior Consultant, Department of Renal Medicine, SGH. Why is there a need for this course?
Transplantation medicine is a multidisciplinary specialty requiring the input of various doctors, nurses, coordinators, and allied health professionals. The course aspires to bring all disciplines to the same level so they can contribute better to the care of solid organ transplant recipients. Organ transplant recipients also get admitted for non-transplant related events, such as childbirth, fractures etc. It is important that we extend transplant education to healthcare professionals in other units, so that the patients get the best care. We also want to create greater awareness of organ and tissue donation and hope that our staff become SingHealth Transplant ambassadors.
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Why is SingHealth well placed to take on the educator role?
We are the biggest healthcare system in Singapore with the largest patient load and case-mix that provides a wealth of clinical experience. We also have top notch educators, highly respected mentors, strong partnerships with Duke-NUS and Yong Loo Lin School of Medicine as well as a robust educational system for support. Most of all, we have strong leadership that understands the value of education and the importance of how good education translates into good patient care.
What’s next?
We hope to build on the course and make SingHealth Transplant a regional training centre for transplantation.
What advice would you give to those keen on learning more about transplant?
The best way to learn is to be part of the transplant unit and work with them in caring for patients.
What got you interested in transplantation medicine?
Our duty as healthcare providers is to make a difference to the lives of our patients and their families. I was fascinated by how, overnight, I could stop dialysis in a patient by giving them a successful kidney transplant. I was even more inspired by the tremendous change in the lives of the patients and their family members. In fact, the only reason I took up renal medicine as a specialty was to eventually become a transplant physician.
LIFE at SGH Campus | Mar/Apr 2013
What is the most memorable lesson you’ve learnt over the years?
To have the courage to do what is good for the patient. I remember when we did our first ABO (blood groups) incompatible kidney transplant in 2009, we didn’t reach the desired antibody level despite the patient having received a significant number of plasmapheresis procedures to remove antibodies. After a phone consult with our Japanese advisor in Kyoto, we went ahead despite the higher antibody level and the patient did not reject the new organ. If I did not trust my Japanese advisor and let the fear of failure overcome me, the patient would
have been subjected to more plasmapheresis with more potential problems. We may then never had done this transplant!
What keeps you up at night?
When there is a transplant!
What do you do to unwind? I am an avid cyclist and try to cover 100km each week,
weather permitting. My dream is to participate in a pro-cycling competitive event one day. I also unwind by spending time with my eldest daughter. Whenever a kiddy movie is released, we will go on movie dates and spend the whole day out. Nothing is more relaxing than the freedom that a bicycle ride gives you, and the love that you feel with your kid when you are spending quality time together.
“Transplantation saves a life and changes the lives of many. So it is important that all our staff have some knowledge of transplantation medicine and help spread the support for organ/tissue donation.”
The Participants speak
Courses coming up
“The course provided a comprehensive overview of the transplant activity and gave me the opportunity to update my knowledge of managing kidney transplants. My team-mates and I are looking forward to implement what we’ve learnt.”
“Through the course, I learnt about the complexities in treatment in organ transplantations and the various components for a successful transplant. I will be conducting in-house training with the nurses, and remain an advocate for organ transplants.”
— Dr Egi Edward Manuputty, Gading Pluit Hospital, Jakarta, Indonesia
— Nurse Clinician Andrea Choh, Ward 64 (Renal), SGH
Organised by SingHealth as part of the 19th Asian surgical Congress and 1st SingHealth Surgical Congress.
• Surgical Transplant Workshop - 18 Jul 2013
• Advanced Transplant Course - 19 Jul 2013
“This course expanded my knowledge in transplant management, such as surgical and medical complications post-transplant. I intend to share my learning with colleagues during our Journal Club session; and use it to revise our Department’s liver transplant nutrition management protocol and provide guidance to dietitians who are new to this specialty area.” — Ms Cherry Li, Dietitian, SGH
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nursingrch resea
Brought to you by the Nursing Research Council
ACQUIRE
Appraise
Apply
Formulate Focused Question
Relevance?
Clinical Applicability
Search The Literature
Validity?
Individualised Care
Retrieve Information
Results?
Appraising results Following the earlier issues of our newsletter, you have completed the five steps of: 1. Formulating a focused question 2. Searching the databases 3. Retrieving relevant articles 4. Appraising the articles’ relevance to your question 5. Appraising the validity of the articles It is now time to appraise the articles in detail for the results.
Results
When appraising the results, we look at how good the intervention was (as compared to a control). A reviewer will ask the following questions:
Evidence-Based Nursing is a systematic approach to the acquisition, appraisal and application of research evidence to guide nursing care decisions. The three main skills are: Acquire, Appraise and Apply. 14
• How large was the treatment effect?
(The relative risk reduction and absolute risk reduction give us an indication of the treatment effect)
• H ow precise was the estimate of the treatment effect? (What were the confidence intervals?)
LIFE at SGH Campus | Mar/Apr 2013
Relative Risk Reduction (RRR) Absolute Risk Reduction (ARR) Number needed to Treat (NNT) Confidence Interval
Proportional reduction in rates of bad outcomes between experimental and control participants in a trial and is calculated as Control event rate – Experimental event rate Control event rate
Control event rate – Experimental event rate
Reflects the effectiveness of the intervention by assessing the number of people who must be treated with the intervention in order to prevent 1 additional bad outcome. NNT is calculated as the inverse of ARR. Confidence intervals reflect the magnitude of the uncertainty surrounding the treatment effect. If the interval is wide, the estimate lacks precision and one cannot be sure of the true treatment effect. On the contrary, a narrow interval allows us to be more confident of the results.
Example
A trial on a pressure redistributing device found that 15% of patients in the intervention group developed pressure ulcer as compared to 38% in the control group. In this study,
• T he Relative Risk Reduction = (38-15)/38 = 0.6 (i.e., a 60% reduction in relative risk)
• The Absolute Risk Reduction = 38-15 = 23% And the Number Needed to Treat is 1/23 = 5 (i.e., five patients needed to be treated with the device in order to prevent development of pressure ulcer in one patient.)
This is the sixth of an eight-part series on Evidence-Based Nursing. Look out for the rest of the articles in subsequent issues. For details on the first five steps, access the previous issues at: http://mysinghealth/SGH/ Nursing-Intranet/QINResearch/ Nursing-Research/Newsletter/
Reference Cullum N (2001) Evaluation of studies of treatment or prevention interventions. Part 2: applying the results of studies to your patients. Evidence Based Nursing, Vol 4, pg 7-8.
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nursingrch resea
Performing an effective search efficiently How can you get an answer to a clinical problem if you only have 10 minutes to spare? An insight of databases and the hierarchy of pre-appraised evidence will help you to keep up with evidence effectively and efficiently.
systems Summaries Synopses of Syntheses
Start search Start your search from the highest possible level available.
Syntheses Synopses of Single Studies Studies
Level
Examples of resources
Examples of databases
Systems
• Computerised decision support
Summaries
• Evidence-based clinical practice
• Clinical Evidence (www.clinicalevidence.com) • Dynamed (www.ebscohost.com/dynamed/default.php) • UpToDate (www.uptodate.com) • Registered Nurses Association of Ontario (www.rnao.org) • National Guidelines Clearinghouse (www.guideline.gov)
Synopses of Syntheses
• Evidence-based abstraction journals
• ACP journal club (www.acpjc.org) • Evidence-based medicine (ebm.bmj.com) • Evidence-based nursing (ebn.bmj.com) • Database of Abstracts of Reviews of Effects (www.crd.york. ac.uk/crdweb/Home.aspx?DB=DARE)
Syntheses
• Systematic reviews
• ACPJC PLUS (plus.mcmaster.ca/acpjc) • E videnceUpdates (http://plus.mcmaster.ca/ evidenceupdates) • Nursing+ (plus.mcmaster.ca/np) • The Cochrane Library (www.thecochranelibrary.com/)
Synopses of Single Studies
• Evidence-based abstraction
• ACP journal club (www.acpjc.org) • Evidence-based medicine (ebm.bmj.com) • Evidence-based nursing (ebn.bmj.com) • D atabase of Abstracts of Reviews of Effects (www.crd.york. ac.uk/crdweb/Home.aspx?DB=DARE)
Studies
• Original articles published in journals
• Pubmed (www.pubmed.gov)
Reference DiCenso A, Bayley L, Haynes RB (2009) Accessing the pre-appraised evidence: fine tuning the 5S model into a 6S model. Evidence Based Nursing, Vol 12, pg 99-101
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LIFE at SGH Campus | Mar/Apr 2013
Sitting right!
I
n the last issue, we highlighted the use of a simple product evaluation trial to help us in our procurement decision.
In this issue, we describe the use of pressure mapping to inform the purchase of pressure-redistributing seat cushions. Pressure mapping systems determine the actual pressure between a body surface and the surface that the patient is lying or sitting on. It provides information on what’s going on under our patient’s skin, potentially alerting us to high-pressure areas. Typically, blues and greens represent lower pressure areas, while oranges and reds indicate areas of higher pressure.
Case study
Recently, we needed to evaluate whether a two-inch, three-inch or four-inch seat cushion would provide the best relief for our patients while they were sitting on a chair. Using a subject who is 72 kg and 1.72m tall, seated on our hospital high-back chair, we found the following:
Pressure Mapping Baseline No seat cushion
Pressure Mapping Two-inch seat cushion
Pressure Mapping Three-inch seat cushion
Pressure Mapping Four-inch seat cushion
Key findings:
• The subject could not rest his feet firmly on the ground with a four-inch seat cushion. This resulted in higher pressure on the sacrum.
• A three-inch seat cushion is ideal in this case, but more importantly we have to ensure the provision of proper foot rest so patients’ feet are well-supported.
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quality pulse
Brought to you by Service Operations, a unit of Operations and Performance Management
The hottest six packs in SGH! 92% , up from 75%
Every day, our Occupational Therapists had to play a guessing game: Which hotpack is the hottest!
Lee Hong Rui, Occupational Therapist, with a red hotpack.
frequency of picking a warm enough hotpack
H
otpacks serve as a form of superficial heating agent for muscle relaxation, usually applied to the limbs and upper back in preparation for therapy. They are heated for about 20 minutes in hot water in a hydrocollator to about 60 – 70 ⁰C, for effective heat treatment. As the hotpacks look similar, no one knows which one has recently been used or is warm enough. Using Lean Principles of visual management, the therapists initiated a rapid improvement event (RIE). The first step was to sew a unique colour patch onto each hotpack. Next, they bought six timers, each coloured to match the six hotpacks. The therapists will start the timer whenever the matching hotpack is placed in the hydrocollator, and stop the timer when the hotpack is removed. A pre and post-RIE study showed remarkable improvements. Hotpacks chosen were almost 5⁰C hotter, and the tendency of choosing a hotpack that was below optimal temperature was significantly reduced.
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Respect People & Their Ideas In a Lean organisation, everybody is valued as an important member of the company. Ideas from all employees are respected.
QI chat 1. How long have you been involved in Quality Improvement (QI)?
I first got involved as a first-year Registrar working with a consultant on his Clinical Practice Improvement Programme (CPIP) project. I never thought much more about QI till I attended the CPIP course myself several years later. That inspired me quite a lot. It was nothing like anything taught to us in medical school or training. QI was never an emphasis or even part of medical curriculum in the past. That is ironic because delivering good quality patient care is fundamental.
2. How has the quality culture evolved over your 10 years in SGH?
Definitely QI is taking off exponentially. When I was a houseman, it wasn’t even talked about. Now QI is firmly recognised as something core. Senior management and clinicians are embracing the quality culture wholeheartedly.
LIFE at SGH Campus | Mar/Apr 2013
I feel we can speed up the process by not doing 'Step A'
'Step A' is redundant in today's context. Let's remove 'Step A' from our process
You've only been here for less than a year and you're telling me how to do things?
.......
Junior staff Manager Director Manager
Dr Emily Ho, Consultant, Endocrinology, led a team from Service Operations and Diabetes Centre to improve operational flow and waiting time. The project won a Merit Award at the Healthcare Quality Improvement Conference in November 2012. Previously it seemed that mostly nursing colleagues were involved in quality projects. Now doctors are more involved too. It is now even made a core competency in Residency training programmes for junior doctors.
3. What project has left a deep impression in you?
What I find most inspiring is the passion some healthcare providers have for their work that they seek out ways – even simple ones – to improve the care they provide. These projects impress me, just by the sheer palpable passion of the people behind them.
4. What are the challenges you’ve faced in a QI Project? Definitely the most challenging is working with different individuals with very different priorities. Sometimes too many varied enthusiastic ideas from within the team make it difficult for everyone to move in unison. In a situation like this, being tactful and managing compromise helps. However I find this easier said than done in a lot of circumstances.
5. Have you applied QI in your personal life too?
After the SGH LEAN workshop I tried “eliminating waste” mostly in
“The best medical knowledge or equipment is not enough. The success or failure of delivering proper care involves systems, teams, workflows and the seamless integration of these.”
terms of personal time. My greatest challenge is to maintain an orderly and efficient household with two hyperactive preschoolers. Somehow the concept of predictability doesn’t exist in the world of children and their tantrums! Still, trying to do things more efficiently like laying out children’s uniforms, water bottles and even shoes and socks at the door the night before saves me some minutes in the morning mad rush.
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spree in action
SingHealth award grows
S
ome 2,500 service champions from 19 institutions received the Singapore Health Quality Service Award this year. New participants came from the private sector as well as the Intermediate and Long-Term Care sector.
A/Prof Tan Ban Hock
Alice Ang Eng Hong
Head and Senior Consultant Department of Infectious Diseases, SGH
Lim Siew Choo
Senior Dietitian Nutrition and Dietetics Department, KKH
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our r e p u s rs sta
Principal Enrolled Nurse Urology Centre, SGH
Chia Li Sen
Patient Care Assistant Ward 56, NHCS
Samantha Ong Sau Fong
Asst Manager Service Quality Department, KKH
LIFE at SGH Campus | Mar/Apr 2013
Neonatal ICU, SGH
Best Team – Clinical Practice Improvement
Ward 77, SGH
Best Team – Service Initiative Improvement
an sgh moment
Faced with a patient whose condition was deteriorating, Bharatha Devy Araganandhan stepped up and activated the medical team to attend to the patient. A Principal Enrolled Nurse at the Operating Theatres, her main role is to bring patients from the Same Day Admissions Centre to the Operating Theatre. In taking the initiative, she went beyond what was expected of her and earned the compliments of Nurse Clinician Irene Goh of Same Day Admissions Centre, who called her “an excellent partner”.
Initiated by SingHealth in 2011, these awards honour healthcare professionals who demonstrate remarkable commitment to delivering quality care and excellent service. It has since become the largest service quality event dedicated to the healthcare service in Singapore. Participating institutions outside of SingHealth: • Singapore Cord Blood Bank • Ang Mo Kio-Thye Hua Kwan Hospital • Econ Healthcare Group • Ren Ci Hospital • St Luke’s Hospital • NTUC Eldercare • Man Fut Tong Nursing Home • Mount Alvernia Hospital • Thomson Medical Centre
“The patient was at the Same Day Admissions Centre on 17 October 2012 when she complained of chest discomfort at 8am. We called the Operating Theatre for an anaesthetist but nobody was available. I sought Bharatha’s help, and she quickly located and brought an anaethestist to see the patient. At 8.35am, Bharatha returned to bring the patient to the Operating Theatre for the scheduled surgery. She saw me attending to the patient who has turned cold, sweaty and in much pain. Immediately, she activated the team of anaesthetists to resuscitate the patient. During this period, Bharatha stayed to help us with the patient’s care till she was sent to the Operating Theatre for further medical management . I am impressed with her calm disposition and prompt action. Kudos to Bharatha!”
Read the stories of the winners at http://mysinghealth/singhealth/shqsa/
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campus buzz
New one-stop outpatient centre
S
GH is positioned to become a regionally-known centre for complex Rheumatology and Autoimmune disorders with the opening of a new outpatient centre at Block 5 in March this year.
The Autoimmunity & Rheumatology Centre (ARC) will be the first such centre Prof Julian Thumboo. in the region to provide a one-stop service dedicated to these conditions. It will leverage on the hospital’s strength in having expertise in most if not all adult medical and surgical specialties, as patients with complex Rheumatologic conditions require multi-disciplinary care. As part of the one-stop service, the ARC will also provide selected physiotherapy and occupational
Education and research will be integrated with patient care at ARC.
therapy services as well as drug management and patient education through on site and virtual monitoring clinics led by Advanced Practice Nurses and Pharmacists. This will further facilitate the development of team-based care by Rheumatologists, Nurses and Allied Health Professionals. “There is an increasing demand for Rheumatology care because of our growing population, as well as for training and research in Autoimmunity and Rheumatology. We hope to grow the ARC into a regionally-known centre for patient care, education and research,” said Prof Julian Thumboo, Head of Rheumatology and Immunology. He added “We are grateful for the support from Senior Leadership, and colleagues from Facilities Development, SOC Administration, Service Operations, Clinical, Nursing, Allied Health and other departments in developing the ARC to better serve patients”.
The Rheumatology Monitoring Clinic at the ARC This clinic will be led by an Advanced Practice Nurse (APN) or a Pharmacist, each seeing patients on a different day of the week. APNs have at least three years’ experience in their chosen specialty and completed Master’s degree education. Senior Principal Clinical Pharmacist Kong Ming Chai, and APN (Intern) Yee Sow Ling, who is serving her one-year internship as APN after completing her Master’s degree studies last June, tell us more about this clinic.
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Yee Sow Ling will be the APN leading the monitoring clinics with Pharmacist colleagues.
LIFE at SGH Campus | Mar/Apr 2013
What kind of services does the monitoring clinic provide?
APN (Intern) Yee: “In this way, we help to free up the Rheumatologists’ time, enabling them to see more new patients or more complex cases.”
Mr Kong: “We monitor stable patients with inflammatory arthritis, who have been prescribed a Disease Modifying AntiRheumatic Drug (DMARD), for side effects, and to ensure that the disease is under control. Both the APN and Pharmacist can issue prescriptions according to an approved protocol.” APN (Intern) Yee: “Besides monitoring the drug therapy, I also assess the patients’ emotional state, discuss psychological issues, provide patient education and make referrals to other Allied Health Professionals if needed. We will counsel and educate patients if they are found to be non-compliant.” “I have received positive feedback from patients that they have a better understanding of the
What else is different about this clinic at the ARC?
Kong Ming Chai, Principal Clinical Pharmacist, trains pharmacists to run outpatient clinics.
disorders now and are more confident in managing their chronic conditions.”
When does the patient get to see the doctor?
Mr Kong: “The patients will see their attending Rheumatologist on alternate visits to the hospital. We will refer the patient back to their physicians or give them an early appointment if their conditions flare up or if there are adverse drug events,” said Mr Kong.
Better benefits in new collective agreement SingHealth staff will enjoy significant enhancement in benefits, under a new collective agreement signed with the Health Services Employees’ Union on 28 January.
Mr Kong: “The Rheumatology clinic is more challenging than the anticoagulation clinic, for example. There are more lab tests to check and more drugs to monitor. As a result, we need to spend more time counseling patients – to explain the lab results, and to ensure that they comply with medications.” APN (Intern) Yee: “Other than the on-site clinic, we have a Virtual Monitoring Clinic for patients who meet certain criteria. They can have their condition monitored without coming to the clinic at SGH – they do their blood tests at the nearest SingHealth polyclinic and we will be able to look at the results and counsel them over the phone.”
A smoke-free campus Since 15 January, hospital outdoor compounds are also no-smoking zones. The authorities have also extended the smoking ban to all covered walkways, area within 5 metres of bus shelters and all common areas in residential buildings.
These include higher annual limits for hospitalization fees and increase in medical claims; as well as more generous Family Care Leave. A memo with the details can be found on the internet.
On SGH Campus, this means the no-smoking areas now include:
The management and union also agreed to introduce a flexible benefits scheme, where staff could use different benefits according to their life stages. The system is under development and will be rolled out by January 2014.
• All the covered walkways, including the ones
• All our open air carparks and the multi-storey carpark
leading to MRT stations
Please advise colleagues, visitors, service partners and contractors of the expanded no-smoking areas.
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campus buzz
P
roject GroomOver saw 280 volunteers this year, making it nearly twice as big as the 2012 outing. They buddied up on 26 January with the common goal of spring cleaning the homes of elderly and needy residents.
Campus spirit on display Volunteers in full force!
Staff from SGH, SingHealth, National Heart Centre, Bright Vision Hospital and ISS Housekeeping; as well as Residents and students from NUS , Duke-NUS and Nanyang Polytechnic came together with cleaning spirits, big hearts and warm smiles.
Raring to go.
Checking supplies are in order.
Tackling boxes.
New coats of paint for homes.
Armed and ready!
Bright Vision Hospital gears up. Hard at work.
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Appointed
LIFE at SGH Campus | Mar/Apr 2013
DR EVELYN WONG
DR BARRIE TAN BOON YAU
Dr Wong, Senior Consultant, has been in SGH since 1997. She is the Deputy Director of the SGH Trauma Service. She is also a faculty member of the NUS-YLL School of Medicine, the Duke-NUS Graduate Medical School and Emergency Medicine Residency Program.
Dr Tan is the Director of the Centre for Hearing and Ear Implants, SGH. He is a Senior Lecturer with the NUS-YLL School of Medicine and is a faculty member of the SingHealth Family Medicine Residency Program.
Head, Emergency Medicine Dept, SGH
ASSOCIATE PROF TAN MANN HONG
Head, Orthopaedic Surgery Dept, SGH
A/Prof Tan is the Deputy Head of Clinical Service in the Department and Director of Musculoskeletal Tumour Service. He played a key role in setting up SGH as the main referral centre for musculoskeletal tumour surgery and limb salvage reconstructive surgery. He holds appointments in Duke-NUS Graduate Medical School and NUS-YLL School of Medicine.
What have you missed? Opra, Dolly and Phua Chu Kang have all been to our Quality Convention. You never know who’s our celebrity host this year!
Head, Otolaryngology Dept, SGH
ASSOCIATE PROF TAN BIEN KEEM
Head, Plastic, Reconstructive and Aesthetic Surgery Dept, SGH
A/Prof Tan is the founder and Elected Vice President of the newly formed Singapore Reconstructive Microsurgery Society. Known for excelling in all three areas of clinical service, education and research, he has won the Young Investigator Award, SGH Scientist Award, Best Free Paper and Best Clinical Teacher awards. Dr Tan also teaches at the Duke-NUS Graduate Medical School.
Quality Convention 2013 27 March Wednesday Deck on 9
Experiencing Quality SGH Quality Convention 2013
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10 tips for healthy footcare
time out
From Podiatry Department
1. W ash feet daily with soap and water and dry them thoroughly, especially between the toes. 2. Inspect your feet every day for any signs of trauma e.g. cuts, blisters, swellings or changes in colour.
3. Trim toenails straight across, avoid cutting down the edges.
7. Buy shoes in the later part of the day as feet tend to swell.
4. Keep feet soft and supple by applying moisturising cream every day, but not between the toes.
8. Ensure that there is one-thumb’s width of room from your longest toe to the front of the shoe.
5. Avoid peeling the skin on your feet or using over-the-counter products (e.g., corn plasters) for corns and calluses. Use a foot file or see a podiatrist. 6. Wear socks with shoes and change them daily.
9. Do calf stretches regularly to maintain a good range of movement. 10. Do not ignore foot pain. Consult a podiatrist if you are experiencing persistent foot pain.
Cross culture
L
“
ike other Asians, Filipinos are by nature, respectful towards our elders. We use special addresses for our elders depending on the relationship we have with them and their gender. For example, we call our grandparents, lolo (male), lola (female); for my parent’s siblings, tiya (aunt), tiyo (uncle); for an older brother kuya, an older sister ate. For our godparents, we use ninong (male), ninang (female),” explains Rose Ann Clemente Herrera, a Pharmacy Technician. “Aside from being respectful, most Filipinos are hospitable and jolly by nature... Jolly in a way that whatever problems we encounter, we always try to find the silver lining.” “Sinigang na Hipon is a Filipino sour soup dish, with shrimp as the main ingredient. It is not a common everyday dish as shrimp is expensive, but it is a classic dish found in most Filipino restaurants.”
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Sinigang na Hipon
Ingredients (Serves 4) • 700 g shrimp (with head) • 1 bunch water spinach (kang kong), cut in three-inch length • 1 cup of string beans, cut in two-inch length • 2 medium sized tomatoes, quartered • 1 large white onion, quartered • 8 cups water • 1 pack sinigang mix (tamarind paste available from most supermarkets), 40g. • 2 long banana peppers (long green chili) • 3 tbsp fish sauce (patis) Method: 1. Boil the water in a large cooking pot. 2. Throw in the onions and tomatoes and cook until soft. 3. Put in the sinigang mix and simmer for two minutes. 4. Add the banana peppers and string beans and simmer for three minutes. 5. Add the shrimps and fish sauce and simmer for five minutes. 6. Add the kangkong, turn the heat off and cover the pot. Let stand for five minutes and serve hot with rice.
LIFE at SGH Campus | Mar/Apr 2013
y o ur t a k e
W
50 Shades of Green
e asked you to show us your favourite shot of Mother Nature for Earth Day. Thank you everyone for the overwhelming response – please keep them coming.
Here are some favourites:
“The insect at play signifies a free and carefree life, to me.” — Tan Yoke Chang, Senior Human Resource Executive, Worklife Unit
Our Pick!
Tan Yeong Horng, please contact us to collect your $20 prize voucher.
“I chanced upon the butterfly which stunned me with its long proboscis and legs at the Botanic Gardens. The butterfly reminded me of what we are missing in the urban environment we live in today.” — TAN YEONG HORNG, Hospital Executive, Projects
“This is Mother Nature for us. Every morning is Earth Day for me & my little girl. As we stroll up the slope to the Little Skool House, we stop & take a minute to breathe in the nice cool air. A blessing for us to last through each day!” — NOOR AZMIAH, Senior Staff Nurse, SOC Clinic H
“Lots of space, lots of green, and best of all, fresh air!” — MARIA WONG, worklife Attendant, Worklife Unit
“The fresh start of a beautiful day!”
— AVALYN GAO, HR Executive, Learning and Career Development
NEXT:
DOWN ON THE STREET
We’d like you to take to the streets. Submit your most interesting shot of ‘street life’ and explain your picture. Most interesting entry wins a prize. Send it to mysgh@sgh.com.sg. Closing date: 31 March 2013.
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st a l theage p
How do you eat your burger?
“Plain if I'm in a hurry, succulent if I'm in a celebratory mood, fire-grilled if I'm feeling feisty & with plenty of sides if I'm famished. But no matter the mood, patty or ingredients, the most heavenly way is always with good company” — Nicole Choo, Year 4 Medical student, Yong Loo Lin School of Medicine at NUS.
“When I eat burgers, I like to wrap them in napkins to hold them easily. Then, I simply peel back the napkin, to eat the burger – like peeling a banana!” — HASLINDA BINTE HASHIM, Senior Patient Relations Officer, Support Services, National Heart Centre Singapore.
“For a large burger, I would cut it in two and eat half first. Next I would take out the meat from the second half to eat, and leave behind the bread of that half.” — FIONA LIM, Occupational Therapist
“Oh, for huge burgers, my method is to first take out the top half of the bun and eat this first. Next, using a fork and knife, I will separate and cut up the meat into small pieces, after which I will eat the meat together with the vegetables. Lastly, I will finish off with the bottom half of the bun.” — RACHEL TEO, Senior Staff Nurse, Nursing Administration
“Saving the best bit for last, I will take small bites and eat round the circumference of the burger before tucking into the juicy centre. If the burger comes with large pieces of lettuce, I will hold the burger firmly and bite into it carefully so the lettuce doesn’t slip out or get consumed within the first two bites.” — LORETTA LEE, Senior Manager, Communications, Sengkang Health
“ 1) Open up the burger and remove all the veggies (especially the lettuce and tomato) and give it to my wife who is a vegetarian. 2) My wife on the other hand removes the patty on her burger and gives it to me. 3) Now that I have 2 patties, I slather them up with more ketchup, mayo mustard and a ton of pepper. 4) I then push the patties more to one side so I can eat them first and start on the bread halfway through... Yum! Yum!” — VINCENT PAUL VILENA LAGUTAP, Respiratory Therapist
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