Reducing same-day cancellations of precious CT simulation slots: A quality improvement project

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Background: CT simulation (CTsim) is a prerequisite step in radiotherapy treatment. Each successfully completed CTsim brings a patient a step closer to receiving their radiotherapy. A non-attempt or unsuccessful attempt (both reflected as cancellations) also delays radiotherapy for another patient. Baseline data revealed that 33% of CTsim appointments were cancelled, of which 47% occurred on the same day. Cancellations made on the same day provides little reaction time for slots to be allocated to another patient and leads to inefficiency in resource utilisation. This project aims to reduce the cancellations occurring on the same day from 15.5% to 10% within 6 months at National University Cancer Institute radiotherapy center at Tan Tock Seng Hospital. Methods: A cause-and-effect diagram was constructed to identify reasons attributing to existing same-day cancellations. Multi-voting and Pareto analysis were conducted to identify 3 main root causes. Interventions were introduced and then tested using the Plan-Do-Study-Act approach. Run chart was used to monitor the proportion of same-day cancellations over the total number of CTsim appointments. Results: Three root causes identified were 1) no workflow to check on patient’s adequacy of preparation leading up to CTsim 2) no workflow to identify potential non-attendance 3) no take-home information detailing CTsim process. Interventions introduced included establishing workflow to assess adequacy of patients’ preparation required for successful CTsim and integrating a screening phone call to confirm patient’s attendance two days prior to CTsim appointment day and handing out information sheet detailing instructions for CTsim respectively. We achieved our target in our fourth month and sustained the results for 2 further months. Mean was 5% in the last three months. This reduction of same-day cancellation improves efficiency in resource utilisation and reduces delay in access to radiotherapy. Conclusions: Using quality improvement tools, we have successfully reduced the same-day cancellations of our precious CT simulation slots from 15.5% to 5%.

The first pilot study of expanded newborn screening for inborn errors of metabolism and survey of related knowledge and opinions of health care professionals in Hong Kong

INTRODUCTION

Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM.

METHODS

The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling.

RESULTS

In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years.

CONCLUSION

The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

How patients fare after anaesthesia for elective surgery: a survey of postoperative nausea and vomiting, pain and confusion

INTRODUCTION

Postoperative nausea and vomiting (PONV), and postoperative pain are common during the early postoperative period. In addition to these problems, elderly patients risk developing postoperative confusion. This study aimed to identify the risk factors associated with these problems, and the extent of these problems, in a Singapore inpatient surgical population.

METHODS

Over a period of six weeks, we surveyed 707 elective surgical inpatients aged ≥ 18 years who received general anaesthesia and/or regional anaesthesia.

RESULTS

The incidence of PONV was 31.8% (95% confidence interval [CI] 34.8-41.9). The incidence increased with increasing Apfel score (p < 0.001) and were higher in female patients (odds ratio [OR] 1.74, 95% CI 1.28-2.36), non-smokers (OR 1.72, 95% CI 1.04-2.88), patients with a history of PONV and/or motion sickness (OR 3.45, 95% CI 2.38-5.24), patients who received opioids (OR 1.39, 95% CI 1.03-1.88), and patients who received general anaesthesia (OR 1.76, 95% CI 1.11-2.79). Moderate to severe pain at rest and with movement were reported in 19.9% and 52.5% of patients, respectively. Among the patients who were predicted to experience mild pain, 29.5% reported moderate pain and 8.1% reported severe pain. The prevalence of postoperative confusion was 3.9% in the geriatric population.

CONCLUSION

Higher Apfel scores were associated with a higher risk of PONV and multimodal treatment for postoperative pain management was found to be insufficient. The incidence of postoperative confusion was low in this study.

Chlorhexidine Anaphylaxis Masquerading as Septic Shock

Chlorhexidine is a commonly used antiseptic and disinfectant in the health-care setting. Its usage has increased in recent years with intensive campaigns and infection control guidelines to combat hospital-acquired infections. As a result, patients and health-care workers (HCW) are exposed to increasing chlorhexidine usage. In recent years, adverse reactions to chlorhexidine ranging from allergic contact dermatitis, photosensitivity, fixed drug eruptions, urticaria and anaphylactic shock have been reported. Most have been isolated case reports on adverse reactions occurring in healthy individuals or HCW. We report a case of anaphylactic shock caused by applying chlorhexidine cleansing solution and masquerading as septic shock from left-leg necrotising fasciitis.

Review of critical incidents in a university department of anaesthesia

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

Esophageal atresia and achalasialike esophageal dysmotility

A 14-year-old boy presented with regurgitation, malnutrition, and chronic lung insufficiency with a history of successful repair of esophageal atresia and tracheoesophageal fistula in the newborn period. Barium swallow and manometry results showed achalasia. Hellar operation with antireflux procedure resulted in complete symptomatic relief. Histology and immunohistochemistry including PGP9.5, MAP5, cKit, and nNOS of myotomy specimen showed intact innervation. Although esophageal dysmotility after esophageal atresia repair usually is caused by gastroesophageal reflux and incoordination of peristalsis, the possibility of achalasia should also be considered, because a casual relationship between esophageal atresia and achalasia may exist.

D-2-Hydroxyglutaric aciduria and subdural haemorrhage

D-2-Hydroxyglutaric aciduria (D-2-HG) is a rare metabolic disorder. First reported in 1980, it does not have any well-recognized presentation or specific treatment regimen. Neuroimaging findings are heterogeneous. Subdural haemorrhage has not been a feature of any of the reported cases. This report presents a boy with bilateral subdural haematoma in whom non-accidental injury was initially suspected and subsequent metabolic investigation led to a diagnosis of D-2-HG.

CONCLUSION

In the management of childhood subdural haemorrhages, it is very important that potentially treatable metabolic disorders are detected and that parents are not wrongly accused of injuring their children.

Peripheral nerve blocks for lower limb surgery--a choice anaesthetic technique for patients with a recent myocardial infarction?

Peripheral nerve blocks are associated with minimal haemodynamic disturbance. It is perhaps ideal for high-risk surgical patients who cannot tolerate the adverse consequences of even the slightest attenuation of haemodynamic response. However, peripheral nerve blockade is often perceived to be time consuming and undependable as the sole anaesthetic. In this report, a 56-year-old man with severe sepsis and recent myocardial infarction presents for an urgent above knee amputation. We present the practical benefits of a combined sciatic-femoral nerve block on such a patient.

First case of haemolytic disease of the newborn due to anti-Mur in Hong Kong

The fifth child of a Hong Kong Chinese mother developed moderate jaundice, attributable to antibodies (anti-Mi) against antigenic determinants in GP.Mur (Miltenberger, class III) red cells. Both the father and the eldest sister were of the phenotype GP.Mur. Testing of maternal serum against a red cell panel including cells known to carry the antigenic determinants of some Miltenberger phenotypes revealed the presence of anti-Mur. This report documents the first case of haemolytic disease of the newborn (HDN) due to anti-Mur in Hong Kong.