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Oral Presentations

Scientific Presentations

1) Innovation & Digital Strategies

Presenting author: Hazel Yeo Kai Hui, CGH

Developing an algorithm for automated classification of hearing loss and using artificial intelligence for predicting hearing improvement after myringoplasty: a pilot study

A basic hearing test (audiometry) is a routinely ordered clinical test at the specialist outpatient ENT clinic. There are approximately 13,000 such tests performed annually and this number is expected to increase with the ageing population. Audiometric results are currently manually interpreted by testers who come from varied backgrounds with different levels of training and exposure to audiometry. Since audiometry is an essential test to assist in the diagnosis of ear-related diseases, results must be carefully and accurately interpreted to provide good diagnostic and prognostic information. However, with an increasing patient load, some results may be misinterpreted due to fatigue or differences in skill level. There is hence a need to use an automated classification model. With this basic automation, we can train a deep neural network to predict hearing levels in different diseased states of the ear, including operative procedures such as myringoplasty.

Retrospective analyses of 125 patients who had undergone surgical repair of the eardrum with available pre and post-operative audiogram between Jan 2017 to December 2019 were included in this study. A decision tree algorithm regressor was applied to the audiometric numerical values of 100 patients. This rule-based decision tree algorithm was developed after consulting clinicians who manually interpreted audiograms and was based on validated classification of hearing loss severity and type in the literature. After excluding missing data, a total of 99 patients’ dataset were further used to train the deep neural network to predict post-operative audiometric results.

Decision tree algorithm can accurately and automatically classify hearing loss type and degree based on numerical values as an input, with good internal validity. Regression neural network was able to successfully predict post-operative air-bone gap within +/-20dB. The top three predictors were age, size of perforation and pre-operative air-bone gap.

Automated classification reduces human errors. Algorithm can be integrated with our medical system through a graphical user interface (GUI) where clinicians can key in the pre-operative variables to predict post-operative outcomes. Larger sample sizes are warranted to improve the model architecture. Clinicians can then counsel patients on post-operative hearing outcomes and empower patients to make a more informed decision on surgery.

Presenting author: Kimberly Joseph, SIT

The integration of Virtual Reality in Radiation Therapy Clinical Training Curriculum

Radiation Therapy (RT) training in Singapore includes four years of undergraduate education in the Singapore Institute of Technology (SIT) and clinical placements at RT departments.  Traditionally, academic teaching blocks provide the underpinning theoretical understanding and clinical placements facilitate integration of theory into clinical skills development, offering great value in education experience. However, clinical placements and opportunities for practice are limited, which are further reduced during the pandemic. Moreover, RT technology is expensive, and complex trainings with real patients and active clinical data risk errors. In this project, we aim to develop a RT Virtual Reality (VR) platform that supports training procedures and scenarios that leads to individualized learning. Adding advanced 3D immersive tools may enable understanding of concepts at a higher level than what is achievable in current training programs. While VR has been widely used in medicine, surgery and nursing, its use in RT education is limited and has not been fully explored. SIT RT undergraduates were recruited in this study. A mixed study method was used, including “checkpoints” to provide opportunities for self-testing, practicing and assessment which provide valuable feedback. The VARK questionnaire and Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaires were used to assess students’ learning preference and their acceptance for new technology. Pre- and post-program evaluation was conducted to determine the effectiveness of the VR systems in enhancing their clinical knowledge and skills. A significantly higher median score was found post-VR usage (p<0.02), showing higher VR acceptance than the traditional method. Additionally, no significant differences in VR acceptance were found between uni-modal and multi-modal learners (p>0.05). The VR group also showed a significantly higher score for the perceived knowledge and skills in performing a whole-brain RT (WBRT) procedure (p<0.03). Our studies have shown that VR can bridge the theory-practice gap in RT training through experiential and active learning. While providing a “physical” and protected environment, students can practice simulated clinical scenarios at their own convenience, without the fear of disruptions and the risk of making errors. Hence, integrating the VR system would benefit students’ clinical placements with increased preparedness and skills.

Presenting author: Dr Anthony Goff, SIT

How accurate, clear and accessible is web-based information about knee osteoarthritis in Singapore? A web-content evaluation

Introduction: Symptomatic knee osteoarthritis affects one in ten people over the age of 50 in Singapore, and is most prevalent in Indian and Malay populations. People with knee osteoarthritis are increasingly seeking information from web-based resources. Therefore, it is important that these align to key research evidence and clinical practice guidelines to inform decision making and facilitate engagement with guideline recommended care. This study assessed the accuracy and clarity of information, plus readability and accessibility (i.e. available in multiple languages) of web-based information about knee osteoarthritis included on Singapore-based websites.

Methods: A systematic appraisal of online information about knee osteoarthritis was performed. Searches (“knee arthritis Singapore” and “knee osteoarthritis Singapore”) were performed in July 2021 using google and Bing. The first 20 URLs from each search were screened for eligibility. For accuracy and clarity we matched website content against a 14-item rubric from previous research. The Flesch Kincaid Grade Level assessed readability. We also identified if information was available in the major languages spoken in Singapore (Chinese, Malay and Tamil).

Results: A total of 28 unique websites were included in this analysis. Very few websites provided accurate and clear information across all 14 content topics. Inaccurate information about the pathophysiology of osteoarthritis and surgery was present in 63% and 40% of websites respectively. Just over half of included websites (57%) met recommended readability levels, and very few (11%) provide information in alternate languages. 

Conclusion: The poor accuracy, clarity, readability and accessibility of web-based information about knee osteoarthritis may act as a barrier to evidence-based decision-making and engagement in first-line care. Website owners in Singapore are encouraged to urgently review and upgrade the information about knee osteoarthritis that they provide.

2) Health Services Research

Presenting author: Ng Jia Wen Celeste, SIT

Does suspension of day care and day rehabilitation services during pandemic affect elderly's physical and cognitive functions?

In response to the COVID-19 outbreak, Singapore entered a lockdown phase known as Circuit Breaker (CB) which disrupted community care services. The aims of this study are to (i) examine the impact of CB-related guidelines on the function of daycare and day rehabilitation clients across 2 time periods: pre-CB to immediately post-CB (referred to as CB-period) and post-CB to 6 months post-CB (referred to as post-CB period), and (ii) identify potential factors associated with the change in function. Data were extracted from clinical notes of clients aged 50 and above who were scheduled for day care and/or day rehabilitation services that were interrupted by CB guidelines. Outcome measures of interest were Modified Barthel Index (MBI), Timed Up and Go (TUG) and Abbreviated Mental Test (AMT). A total of 391 clients were included in this study (mean age 78.82±9.06 years; 65.47% female; 93.35% Chinese).

Overall, there was a gradual, statistically non-significant deterioration of MBI, TUG and AMT performance across the study period. When examining subgroups of clients, those who were cognitively impaired were found to experience a greater decline in MBI in the CB-period versus those who were cognitively intact (β=3.29, 95% CI: -5.43 to -1.13, p=<0.01), TUG performance for moderately frail clients deteriorated more than robust clients (β=-5.97; CI -10.069 to -1.869; p=0.005). Additionally, clients who were undertaking maintenance rehabilitation only showed a significant decline in AMT score during the CB-period compared to clients who attended daycare services (β= -1.035, 95% CI = -1.795 to -0.275, p=0.008). Age was also found to be negatively associated with change in MBI and TUG performance across all time periods (MBI CB-period β=-0.12, 95% CI: -0.229 to -0.0195, p=0.02, post-CB period β=-0.17, 95% CI: -0.312 to -0.025, p=0.02;TUG CB-period β=−0.35; 95% CI -0.56 to -0.13; p=0.002, post-CB period β=-0.30; 95% CI: -0.55 to -0.05; p=0.021). Change in TUG performance post-CB period was also significantly associated with baseline MBI (p=0.015). These study findings suggest the potential negative effects of CB-related guidelines on clients outcomes. Selective prioritisation of clients need to be considered if another disruption of rehabilitation service is required in the future.

Presenting author: Soong Jie Lin, SGH

Prevalence of Polypharmacy: A Cross-Sectional Study in Singapore Public Healthcare Institutions

Introduction: Polypharmacy is associated with an increased prevalence of potentially inappropriate medications (PIMs), leading to a higher risk of adverse drug events and medication errors. While polypharmacy and inappropriate medication use have been studied in Singapore previously, this study was the first multi-centre retrospective cross-sectional study in Singapore that determined the prevalence of polypharmacy, evaluated prescribing appropriateness of drugs used in patients aged ≥ 65 years old with polypharmacy, as well as identified demographic factors and common drug classes associated with polypharmacy and use of PIMs between different care settings.

Methods: Discharge prescriptions from five public acute hospitals and outpatient prescriptions from primary care polyclinics, on 2 randomly selected days, were retrospectively reviewed. Patients’ demographic characteristics, number of prescription line items, and drug-related details of prescribed drugs, were collected. Prescribing appropriateness was evaluated by identifying the presence of PIMs using the Beers Criteria. Logistic regression was used to assess the association of demographic characteristics and the type of care setting with polypharmacy and PIMs use.

Results: Polypharmacy was present in 49.9% of all prescriptions (hospitals vs polyclinics, 66.6% vs 35.0%, p<0.001). PIMs were present in 29.8% of elderly patients with polypharmacy (hospitals vs polyclinics, 27.1% vs 34.6%, p=0.010). Patients aged ≥ 65 years old and hospital patients had higher odds of having polypharmacy than patients aged 21-64 years old (OR 2.96, p<0.001) and polyclinic patients (OR 3.55, p<0.001). Drugs for chronic conditions, such as lipid modifying agents, were commonly associated with polypharmacy in both care settings. Drug classes commonly prescribed for patients with polypharmacy included drugs for minor ailments in polyclinics, and drugs for gastrointestinal symptoms and analgesics in hospitals. The most prescribed PIMs were psycholeptics, proton pump inhibitors, orphenadrine, and systemic antihistamines. 

Conclusion: As Singapore’s population ages and chronic disease burden increases, polypharmacy is expected to become more prevalent. Considering the magnitude of polypharmacy and PIMs use in Singapore, more focus should be placed on reducing inappropriate polypharmacy. This study can inform nationwide deprescribing efforts and allow development of tailored strategies for different care settings.

3) Basic/Clinical Research 

Presenting author: Fiona Lim Yun Qian, SGH

Exploring the Relationship between Perceived Falls Risks and Falls Efficacy of Older Adults Admitted into an Acute Hospital in Singapore

Components of effective falls prevention interventions have been widely discussed but little is known about the psychological factors that affect their efficacy. Applying the Health Belief Model, perceived severity and susceptibility to falling may influence one’s receptivity levels towards addressing the risk of falling. A deeper understanding of perceived severity and susceptibility in the context of falling may better inform intervention designs. This study aimed to understand the relationship between self-perceived risk of falling and fall efficacy levels among older adults with higher independent activities of daily living performance in Singapore. Sixty-two participants were recruited from inpatient wards at a local acute hospital. Participants completed two self- report questionnaires, the Staying Independent Checklist (SIC) and the Falls Efficacy Scale – International (FES – I), measuring perceived susceptibility and severity respectively. Participant characteristics were summarized with descriptive statistics. To understand the relationship between self-perceived falls risk and fear of falling among older adults, a one-way ANOVA was used to determine the association between SIC and FES-I scores. To explore the factors associated with higher self-perceived falls risk and fear of falling, stepwise linear and logistic regression with backward elimination was conducted and the dependent variables were FES-I and SIC scores. One-way ANOVA analysis revealed a significant association between FES-I total scores and SIC score categories F(1,60) = 6.277, p = .015). Stepwise regression with backward elimination also found that falls history (β = .292, p = .033), sex (β= .269, p = .042), and FIM lower body dressing (β = -.286, p = .035) had significant associations with FES-I scores. Level of perceived susceptibility and severity of falling should be considered when determining if falls prevention interventions are relevant, regardless of one’s functional ability and physical health status. Future research on these factors to determine the underlying mechanisms which drives health behaviours related to falls prevention can be conducted to improve current intervention programs.

Presenting author: Eileen Lim Chay Ngun, NUH

Comparing the Repeatability and Sensitivity of the Manual Perimetry in Demonstrating the Functional Loss of the Superior Visual Field with a Supra-threshold and Threshold Stimuli

In 2018, the Health Ministry implemented a new guideline assessing the functional visual field loss due to ptosis. Automatic visual perimeter (HVF) testing of the peripheral 60 degree is a standard test to assess the visual loss, manual visual perimeter (GVF) which usually requires a shorter examiner time and can be sensitive in indicating the superior field loss, will be accepted when the patient has two unreliable HVF reports. The aim of this study is to compare the repeatability and sensitivity of a threshold and supra-threshold stimuli with GVF, in demonstrating the functional loss of the superior visual field and the repeatability of the stimuli between the examiners. 

Method: Visual field (VF) of patients with unilateral and bilateral ptosis from dermatochalasis were mapped using GVF, those with known superior VF defects from glaucoma, neurologic disease and etc were excluded from the study. Supra-threshold and threshold stimuli were used to map the visual field, with their upper eyelid untapped and tapped. Another set of VF by another examiner were mapped within 2 months. The superior VF loss at were compared and analysed statistically. 

Result: 18 Asian patients amounting to 34 visual fields were mapped, mainly Chinese with a mean age of 71.8. The mean VF loss at 12:00 meridian was 13.43o±7.42o using supra-threshold, and 12.81o±5.66o using threshold. VF loss from examiner 1 was 15.24o±7.26o using supra-threshold, and 13.89o±5.93o using threshold, and 13.20o±7.43o using supra-threshold, and 13.02o±5.88o using threshold for examiner 2. Intraclass correlation coefficient (ICC) for supra-threshold and threshold stimulus were 0.47 and 0.37 respectively; agreement between examiners was 0.43 at 95% confident interval. 

Conclusion: Reliability was poor but supra-threshold stimulus had a higher reliability; agreement between examiners was low and the agreement was worst when using threshold stimulus. A supra-threshold stimulus for testing the VF loss in patient with ptosis is recommended. The mean VF loss vary depending upon the method of tapping the eyelids, patients’ response and learning curve.

Presenting author: Lee Yu Xian Merwyn, SIT

Effect of Guided Mindfulness Meditation on Novel Motor Learning in Healthy Young Adults

Motor learning is indispensable for fundamental human movement throughout life, from learning of new sports to post-stroke rehabilitation. Mindfulness Meditation (MM) is a promising cognitive strategy that can reduce anxiety and improve attention which may facilitate motor learning. This study aims to examine the acute effects of guided MM on novel motor learning and motor memory retention in healthy young adults. This study was conducted as randomised controlled trials where healthy participants between 18 to 35 years old were recruited. Participants underwent either a 10-minute session of MM or seated rest (Control) before performing 3 blocks of circle tracing tasks using their (1) dominant hand, (2) non-dominant hand, and (3) non-dominant hand with inverted screen display (novel motor task). This was followed by a 10-minute rest before participants underwent a Parametric Go/No-Go cognitive test. 24 hours later, they were reassessed on the same motor tasks. The level of anxiety was assessed via heart rate, State-Trait Anxiety Inventory (STAI) and Visual Analogue Scale-Anxiety (VAS-A). 24 participants were recruited (MM: n=12, Control: n=12). Main effect analysis showed that the heart rate was lowered during guided MM (p=0.03) with a reduction in VAS-A scores in meditators (p=0.01), relating to a lower level of anxiety. Learning effect for the dominant hand motor task was greater in MM group as compared to the Control group (MM=4.2±3.3%, Control=0.3±4.4%; p=0.02). However, no difference was observed in the learning effect for novel task learning between groups (p=0.13). Poorer motor memory retention for non-dominant hand task was observed in the Control group (Day 1= 1.0±0.1; Day 2= 0.9±0.1; p=0.03). For cognitive assessment, MM group showed higher accuracy in target detection in “Easy” level than Control group (76±9% vs. 65±14%; p=0.04) while no differences were detected for other levels (p>0.05). A single session of guided MM produced transient effects in reducing anxiety and promoted sustained attention in simpler motor and cognitive tasks. However, there were no carry-over benefits for novel motor learning. Future studies should explore potential benefits of long-term MM practice for motor learning as this may facilitate motor skills relearning in stroke survivors.

Presenting author: Chua Ningyi Fionn, CGH

Underdiagnosis of Chronic Metabolic Diseases in Patients with Newly Diagnosed Ischaemic Heart Disease

Objectives: Despite community screening efforts for common modifiable risk factors, we observed that chronic diseases such as type 2 diabetes (T2DM) were often only detected at the point of ischaemic heart disease (IHD) diagnosis. Hence, we aim to investigate the prevalence of underdiagnosed modifiable risk factors in patients with IHD.
Methods: We assessed the prevalence of previously undiagnosed cardiovascular risk factors among hospitalized patients with IHD (n=555) and compared the differences between patients with newly diagnosed IHD (IHD-N, 46.5%) and patients with known IHD (IHD-K, 53.5%).
Results: The patients recruited were mostly males (82.5%) of Chinese ethnicity (49.1%). Overall, there was a high prevalence of newly diagnosed hypertension (13.3%), hyperlipidaemia (13.2%) and T2DM (4.9%). Compared with the IHD-K group, prevalence of previously undiagnosed hyperlipidaemia (26.0% vs 2.0%, p<0.001), hypertension (24.8% vs 3.4%, p<0.001) and T2DM (7.0% vs 3.0%, p<0.001) was higher in the IHD-N group. Prevalence of active smoking was high at ≈50% in both groups. The median concentration of total cholesterol and LDL-C were higher in IHD-N group compared with IHD-K group(p<0.001). Dietary habits of >50% of patients in both subgroups did not meet national recommendations for fruits, vegetables, wholegrain and oily fish intake, although IHD-K group compared to IHD-N group had more regular omega-3 supplements intake (23.4% vs 10.4%, p=0.026).
Conclusion: The high prevalence of previously undiagnosed chronic metabolic diseases among patients with newly diagnosed IHD underscores the importance of increased detection efforts as well as emphasis of a heart healthy diet and smoking cessation.

Programme Evaluation Presentations 

1) Innovation & Digital Strategies

Presenting author: Chan Hsin Yi Abigail, TTSH

Digitalised Exercise Brochure (DEB): Exercising Right With Digitalised Exercise Resources

Physiotherapists prescribe home exercises to help patients regain their function. Although patients display understanding when taught with hardcopy exercise booklets, performance at home is often inaccurate. A root cause analysis (RCA) revealed the cause being a lack of clarity of resources, which results in insufficient guidance, leading to reduced accuracy and compliance to exercise and reduced benefits. Additionally, with pre-printed booklets, exercises are limited, affecting suitability of treatment. Hence, by revamping our exercise resource format to show steps and dynamic movements, patients can better understand their exercises, leading to accurate exercise performance, translating to improved patient outcomes. Additionally, by adding new exercises and creating a customisable exercise sheet, therapists can prescribe patient-specific exercises, maximising treatment effectiveness. For phase one of this project, an RCA was conducted. To target the primary root cause of a lack of clarity of resources, the exercise resource format was revamped to include step-by-step photos and instructions. Content creation included photo-taking and creation of instructions to produce exercise pictures. A customisable digital exercise sheet was also created for exercise prescription. To target the secondary root cause of limited exercise variety, new exercises were added. Creation of more exercise pictures is still ongoing to cover a range of exercises. Phase two of this project involves exercise video creation to provide patients with further visual guidance to address the primary root cause. The team is also working with NHG Healthapps team to explore digital exercise prescription using our resources. In the future, we aim to venture into artificial intelligence to create a real-time feedback-guided therapy system using the exercise videos. 286 upper and lower limb exercises in both English and Chinese have been created, a marked increase from 100 exercises available in the hardcopy booklets. After using the new resources, most Physiotherapists surveyed expressed satisfaction with its effectiveness in improving patients’ accuracy and compliance, clarity, and picture quality. The Physiotherapy Department saved approximately $1930 when fewer hardcopy exercise booklets were printed due to reduced demand. In conclusion, the new physiotherapy exercise resources have contributed to improving patients’ accuracy and compliance in performing exercises, translating to better patient outcomes.

Presenting author: Ng Kian Hong, CGH

Automated Batching and Collation of Data from Patient Input (ABCD PI) Sources for Efficient Medication Delivery Service

The data entry and order collation processes for Medication Delivery Service (MDS) are manual, manpower intensive and non-value-added tasks which pharmacy staff in Changi General Hospital (CGH) have to perform daily. This led to a significant reduction in manpower allocation for patient care and accuracy issues with order processing. The aims of this project are to introduce digitalisation tools to enhance efficiency and accuracy of MDS order processing and reduce manpower required for MDS order processing.
A patient registration system (PRS) was created using Excel macros for MDS registration. The PRS allows patient details to be stored in a database upon registration, enabling them to be auto-populated for subsequent MDS orders. Upon scheduling of delivery, the information is automatically transferred to another excel sheet and sorted into respective delivery slots with pre-defined columns. The SikuliX® software is used to automate data entry for MDS orders. SikuliX® is an open-source software that is able to identify and interact with graphical user interface components to automate repetitive tasks. Together with Health Sciences Research, a script was written for SikuliX® to extract required information from the outpatient administration system for newly registered patients and inclusion into PRS database. With FormSG being used as an order platform for MDS, CGH collaborated with Integrated Health Information Systems to develop a script that is able to instantaneously collate and export FormSG orders (received via email) into the desired format for processing.
PRS, SikuliX® and FormSG script significantly reduced the average time required to perform data entry for one order from 1.80 mins to 0.90 mins (p < 0.05), 0.90 mins to 0.25 mins (p < 0.05) and 2.15 mins to 0 mins (p < 0.05) respectively. On average, pharmacy had to process 190 MDS orders daily. A total of 4.20 manpower hours was saved daily and the error rate for data entry was reduced from 1 in 200 orders to zero.
These novel digitalisation tools enhance the efficiency and accuracy of MDS order processing via automation, leading to significant reduction in manpower required and data entry errors respectively.

2) Health Services Research

Presenting author: Tan Xiao Yen Joanna, SKH

Bariatric Nutrition Programme – The Person Beyond the Fats

Effective nutrition management after bariatric surgery is the key to successful and sustainable weight loss, however, there is no specific relevant programme for Singapore’s multi-racial population. Therefore, the Dietitians at Sengkang General Hospital (SKH) have developed and implemented the Bariatric Nutrition Programme (BNP) since December 2020. The BNP is a 7-module programme that aims to increase compliance rate to dietary recommendations, minimise side effects of surgery and maximise excess weight loss. Effectiveness of BNP was evaluated based on the following: compliance with Dietitian’s follow-up visits; excess weight loss (EWL) post bariatric surgery; reported side effects; patients with nutritional deficiencies; stages of change over 6 months. Data of pre- (54 patients, Aug 2018 to January 2019) and post-BNP (91 patients, December 2020 to December 2021) were compared. Pre- and post-BNP patients achieved similar maximum EWL 6-months post-surgery; laparoscopic sleeve gastrectomy: 55% (n=21) vs 56% (n=80); laparoscopic Roux-en-Y Gastric Bypass: 78% (n=3) vs 78% (n=11). BNP patients showed improved compliance (44.5%) to multi-vitamin supplementations recommendations. Attendance rates for BNP clinic sessions showed an increase (84% to 94% at week 4; 54% to 85% at week 8 post-operatively).  BNP patients reported experiencing less frequent side effects (nausea and vomiting: 3.3% vs 9.3%; dumping syndrome: 3.7% vs 1.0%). Minority of BNP patients (3%) suffered from Vitamin B12 deficiency at 6-months post-surgery, which was corrected. At 1-year postoperatively, only 3.3% of BNP patients suffered from iron deficiency, which was corrected. Lastly, 43% of post-BNP patients improved by 2 stages of change over 6 months. BNP is an effective programme to achieve maximum EWL, improved compliance, reduced side effects and nutritional deficiencies after bariatric surgery. A structured programme led by Dietitians, like BNP, is essential to provide effective dietary support peri-operatively to ensure safe, successful and sustainable weight loss to optimize health outcomes.

Presenting author: Tan Shiyun Charmain, KKH

The Autism Primary School Readiness Workshop: Outcomes from pilot runs of a caregiver workshop for parents of autistic children

Children with autism have additional social, emotional, communication and behavioural needs that can make transition from preschool to mainstream primary school a difficult and stressful experience for them and their caregivers. A new caregiver training workshop was developed to provide parents with strategies to support their children through this significant educational milestone. The content covered was 1) Autism in Context, 2) Introduction to Primary School, 3) Supporting Behaviours, 4) Supporting Emotions, and 5) Developing and Maintaining Communication with School, and focused on teaching parents relevant skills to facilitate their children’s engagement and participation in mainstream schools. This paper describes parental perceptions on how the workshop helped, changes in their parenting stress, and sense of parenting competency pre- and post-workshop. The workshop was delivered over two 4-hour sessions for groups of <8 caregivers each run. Parents completed a pre-workshop and a post-workshop questionnaire, rating their abilities to understand and support their child’s needs and work with schools, their levels of stress, and their sense of parenting competency. Data was collected from 24 parents who attended 8 runs of the workshop in 2020 and 2021. Parents perceived that the workshop enabled a positive change in their abilities to understand their child, help their child develop skills, as well as develop and implement behaviour plans for their child (t>4.1, p<0.001). They reported more confidence communicating their child’s needs with school, working together with school, and sharing strategies with school (t>4.4, p<0.001), but not about how the school will treat their child, or their comfort level in approaching the school. There were no significant differences in parents’ stress levels and sense of parenting competency. The Autism Primary School Readiness workshop has made positive changes in parent’s perceptions of their ability to support their children. Parental stress levels and sense of parenting competency did not change significantly, likely due to the short-term nature of the intervention and with the post-workshop measures done immediately after the workshop. Future evaluations should consider collecting 3-6 month follow-up data, and/or measures of how the parents and children are coping after the children start primary school.

Presenting author: Dr Beron Tan, KKH

Enhancing the Early Detection of Psychological Distress in Paediatric Oncology Wards:  A Quality Improvement Initiative

Internationally, psychological distress is recognised as the 6th key indicator of vital signs, and it is commonly experienced among children with cancer. Regrettably, the screening of psychological distress has yet to form part of the clinical routine in paediatric oncology wards. The current quality improvement initiative focused on the introduction of a nurse-administered brief mental health screening for children with cancer in the wards. The mental health screening tool was based on the Emotion Thermometers (ET), commonly used in the childhood cancer population. The ET had good psychometric properties, and consisted of psychological distress, anxiety, depressed mood, anger and needing help. The outcome measures were based on the 1) staff evaluation form, and 2) the number of patients detected to have elevated scores on the ET. The evaluation form examined feasibility constructs such as ease-of-use, administration time, impact on nursing workload, usefulness, nurse-patient rapport, and empowerment of nurses across a 7-point Likert scale. Additionally, patient with elevated scores on the ET were followed up by Psychology Service via a novel and simplified referral process using FormSG. The ET were trialled over 3 months (February-April’22) based on 2 cycles of the Plan-Do-Study-Act (PDSA) framework. Each PDSA cycle lasted for a month, and nurses’ feedback on the use of the ET were collected before and after each cycle. In total, 10 nurses participated in this quality improvement initiative, and 45 patient responses were collected. Overall, nurses rated higher on the staff evaluation form after trialling the ET compared to baseline (i.e., before ET trials), and this represented a small-moderate effect size (Glass’s ∆ = 0.33). Furthermore, 80% of the nurses reported that the most useful aspect of the ET was to identify and understand what their patients were feeling. Regarding the ET, approximately 17% of the inpatients were detected to have elevated scores on one or more of the ET domains; this detection rate was similar in both pilot trial groups (relative risk = 1). This quality improvement initiative supported the feasibility of incorporating ET as an essential brief mental health screening tool in the paediatric oncology wards.

3) Basic/Clinical Research 

Presenting author: Lynette Goh, NUP

Impact of an interactive health corner in promoting long term dietary changes

An unhealthy diet is a major risk factors for chronic diseases. Although studies had shown that nutrition education and cooking demonstrations have resulted in favourable dietary changes, it is unclear whether this is sustainable for longer periods, especially among individuals with chronic diseases. This study aims to evaluate the long-term impact of a nutrition-led cooking programme on dietary behavioural patterns based on My Healthy Plate (MHP).  This was a quasi-experimental study involving patients with chronic diseases in two polyclinics. A self-administered survey was done at baseline, 6 months and 1 year for both intervention and control group. Participants in the intervention group were exposed to the health corner which provides nutrition education and cooking demonstrations. 216 participants completed the study at one year with a follow-up rate of 86%. Adjusted risk ratio (aRR) were obtained from negative binomial regression. Participants in the intervention group were more likely to report knowing and adhering to the components of MHP at 6 months (aRR 1.83, 95% CI 1.12-2.99) and 1 year (aRR 1.54, 95% CI 1.10-2.16). Participants in intervention group were less likely to add salt or sauces to food at 6 months (aRR 0.29, 95% CI 0.12-0.75) and 1 year (aRR 0.21, 95% CI 0.07-0.61), and more likely to remove fat when eating meat at 1 year (aRR 0.30, 95% CI 0.13-0.67). The health corner had a positive impact of helping patients achieve MHP recommendations, not adding salt and sauces to their food, and removing animal fat before eating. There is potential for expanding this initiative to improve healthy eating practices in other polyclinics.

Programme Development Presentations 

1) Innovation & Digital Strategies

Presenting author: Neo Zhi Yang, SGH

Gamifying Pharmacy Resource Management Training through PRISM – PhaRmacy Interactive SiMulator

Pharmacy floor manager (PFM) are responsible for ensuring smooth pharmacy operations by managing manpower resources and resolving operational chokepoints. Trainees feel stressed and inadequately prepared for the operational intensity of an outpatient pharmacy which processes 1050 prescriptions daily. 

PhaRmacy Interactive SiMulator (PRISM) game was developed in-house using the FRamework for AGile Gamification of Learning Experiences (FRAGGLE) to provide trainees with a safe, virtual training platform to hone their resource management skills and Standard Operating Procedure (SOP) knowledge on pharmacy workflow processes. 

Phase 1 (Declaration): Trainees playing as PFM had to apply an appropriate manpower allocation strategy to manage the pharmacy waiting queue while resolving ad-hoc pharmacy-related issues, presented as 5 multiple-choice questions (MCQs). Measurable objectives included keeping the pharmacy waiting time low in at least 11 out of 21 rounds, and correctly answering ≥80% of MCQs.

Phase 2 (Creation): PRISM was created as an excel-based game made up of simulated 30-minute time-intervals for 21 rounds, using a dataset consisting of pharmacy patient flow data and time-study results of prescription processing output at various pharmacy stations. Game mechanics existed as macro dashboards, enabling visualization and correlation of the manpower allocation strategy to pharmacy waiting queue. 

Phase 3 (Execution): Alpha tests were conducted over one month among the development team to identify and address game design and functionality issues. Beta test was subsequently conducted over 2 weeks with 5 users through an open-ended survey, which obtained feedback on gameplay experience.

Phase 4 (Learning): Players’ performances were presented as a comprehensive summary report with data tables, charts, feedback and rationales of MCQ answers. 

Presenting author: Karishma J Surtani, Yishun Health

eLEARN Nutrition Programme –  Development of an Online Nutrition Training Programme for Healthcare Workers

Nutrition is an important part of care for hospitalised patients and residents living in the community. Training in nutrition was offered to Community Nurses within the Population Health and Community Transformation (PHCT) Team to support them in caring for their residents. As the training was opportunistic and fragmented, it resulted in inconsistent and varied nutrition knowledge levels. It is also a challenge to gather teams for training, especially with safe distancing measures and split teams in effect during the COVID-19 pandemic. Hence, there is a need to review the nutrition training programme to better support the team. The eLEARN Nutrition Programme aims to educate and empower healthcare workers with evidence-based nutrition knowledge and strategies to reinforce nutrition messages in their interactions with patients and residents. This aligns with the move towards transforming the healthcare workforce through upskilling and providing transdisciplinary learning opportunities. The nutrition training framework and content was developed by the Nutrition & Dietetics (N&D) Department and supported by the Allied Health Services & Pharmacy (AHS&P) Office. PHCT provided input on the common nutrition issues and challenges faced by the residents they cared for, which was key to the development of the topics.  An online learning platform was identified as the most feasible and effective way to ensure access to the nutrition information. The programme is asynchronous and designed in two parts: Core Course featuring the basic foundational concepts in nutrition and Continuous Courses featuring elective, advanced topics. Topics are co-created with learners to ensure relevant and useful content. Each course is bite-sized and include pre and post quizzes, and additional reading materials on the NHG eLEARN platform. We piloted the programme with PHCT, Allied Health Professionals (AHP) and Nursing Leads in 2021. 97 learners completed the Core Course and 97% provided positive feedback. We were able to identify the needs of different groups of healthcare workers, prioritise the topics for development, and improve the work processes. We are currently working to roll out the programme to include nurses within the hospital and community setting and relevant AHP.

Presenting author: Julia Wang Xinyi, KKH

Pretend Play Workshop goes Online

Pretend Play is important for a child’s development but caregivers in Singapore may overlook it. There tends to be insufficient time in typical individual outpatient therapy sessions to fully address the breadth and depth of play knowledge. Thankfully, research suggests that workshop-based caregiver training is a cost and time-efficient option. As in-person workshops were suspended during the Covid-19 outbreak, it was imperative that the Pretend Play workshops be delivered online while still maintaining effectiveness. The Pretend Play workshop is a three-hour program designed to empower caregivers on play development. Caregivers learn to identify their child’s play skills, create a personalised play plan, and practice Facilitating Strategies (FS). The outcomes are to increase caregivers’ self-efficacy and facilitation skills in engaging their child in Pretend Play. Caregivers are offered a one-on-one session with their Occupational Therapist within one to two months after the workshop for continued support. The workshop was redesigned to be conducted via Zoom. Caregivers utilized screen annotations to identify FS in videos of parent-child interaction. Additional visuals were included to improve understanding of handouts and attention to slides. Experiential learning methods such as role-playing, live modeling, and toy exploration were more difficult to adapt. Group discussions of new video depicting both ideal and less ideal FS application replaced role-playing. One video was paused at various points to allow for discussion about how caregivers would use the FS if they played the role of the parent. Outcomes were measured using pre, post, and review surveys. So far, four runs have been completed with 30 caregivers and 28 responded to the surveys. According to the post-survey results, all the caregiver respondents were satisfied or very satisfied with the workshop and would recommend it to other parents. Immediately following the workshop, caregivers' self-efficacy in engaging and facilitating their child's pretend play increased significantly. While the implementation is in its early stages, the ongoing discussion helps to refine the instructional method and content. Some areas to improve for online delivery include identifying participants who need more support during the session and accurately identifying the profile of parents who will benefit from online training.

2) Health Services Research

Presenting author: Jessica Lim Pei Ying, SKH

Continuum of Care - Inpatient to Outpatient Speech Therapy Referrals

Patients often require ongoing speech therapy services upon discharge from an acute setting. 41% of patients who were seen by speech therapists (ST) in SKH were not referred to speech therapy services post-discharge, leading to a gap in their continuum of care. Patients with dysphagia who do not receive timely reviews may have poorer outcomes such as increased risk of aspiration pneumonia and reduced nutrition. A gap in rehabilitation may also impede patients’ recovery. Our project thus aims to reduce the percentage of patients not referred to ST services post-discharge to 20%. The root causes of the problem were identified through analysis of patients’ data, and surveys and interviews of STs to gather perspectives and management of patients’ discharge process. Two primary causes were identified. Firstly, STs were uninformed of discharged patients due to automatic removal of patients’ admissions from Citrix list post-discharge. Secondly, STs had differing opinions and management of the discharge process for patients. Our final PDSA cycle introduced the use of an advanced visit list which taps into new and advanced features in Citrix to allow tracking of discharged patients. STs can thus be informed of discharged patients and raise appropriate and timely referrals. A standardised discharge process for various discharge destinations was also implemented within the department. We realised that differing criteria and referral process for various discharge destinations can be convoluting. Consolidating different expertise and experiences from STs regarding various discharge destinations helped to streamline the discharge process to become more accessible and efficient. A consolidated source of information was particularly useful in orientating the new hires to the discharge process, which might be unfamiliar to them. Rethinking and innovating beyond our current practices have allowed us to implement underutilised advanced Citrix features in our solution, which resolved the difficulties in tracking of discharged patients. The use of technology functions has played a significant role in enhancing our workflow. Moving forward, gathering feedback from the ground with regards to potential upgrades and modification to Citrix features may help to further improve speech therapy service delivery and work process.