1) Beyond Hospital Walls
Presenting Author: Dr Choo Pei Ling, Singapore Institute of Technology
Timed Up and Go (TUG) Reference Values and Predictive Cut-Offs for Fall Risk and Disability in Singaporean Community-Dwelling Adults
The 'timed up and go' (TUG) test is a simple and widely used test of overall functional mobility. Nonetheless, there is a paucity of TUG normative data among Asians who differ in habitual gait speed and fall risk from Caucasians. The objectives of this study were to determine TUG reference values and optimum cut-offs predicting fall risk and disability for community-dwelling adults. The design was cross-sectional for Study 1- the Yishun Study and longitudinal for Study 2- the Singapore Longitudinal Study. Study 1 comprised 538 non-disabled, community-dwelling adults aged between 21 and 90 years. Study 2 comprised 1356 community-dwelling older adults aged ≥ 55 years. Physiological falls risk (PFR) was determined using the Physiological Profile Assessment (PPA) in Study 1. Disability was assessed using the Barthel Index and the Lawton scale in Study 2 at baseline and 3-year follow up in Study 2. In Study 1, mean TUG time for individuals aged 60-74y was 9.80s, shorter than values reported for Caucasians of 12.30s. It was significantly associated with high PFR (OR:1.14, 95%CI 1.03-1.27), 74.0% agreement, Cohen's kappa=0.314, (95%CI 0.238-0.390); AUC=0.85 (95%CI 0.80-0.90), cut-off of 10.2s discriminated high PFR from low PFR with 84.4% sensitivity and 72.6% specificity. In Study 2, threshold for observing significantly increased risk of disability was ≥9.45s for prevalent disability (OR: 2.98, 95%CI 1.41-6.78), functional decline (OR: 2.68, 95%CI 1.33-5.80), and incidental disability (OR: 2.25, 95%CI 1.08-4.97). The results show that TUG reference values and cut-offs predicting fall risk and disability for community dwelling older adults in Singapore are consistent with Asian data and differ from Caucasians. In conclusion, TUG could be used to guide development and evaluation of risk screening of adverse health outcomes across the life span in Singapore.
Presenting Author: Jeslyn Phoen, Changi General Hospital
The Impact Of The Health Peers Programme On Dietary and Exercise Habits in Singapore The Ministry of Health Singapore declared War on Diabetes in April 2016. In line with this, Changi General Hospital launched the Health Peers Programme in January 2017. The objective of this community-based initiative is to equip lay persons or "Health Peers" with the skills and knowledge to be peer coaches, allowing them to support residents who are at-risk or diagnosed with diabetes to adopt healthy exercise and dietary habits. The unique aspect of the Health Peers Programme includes a training curriculum developed and delivered by a multi-disciplinary team of healthcare professionals: sports medicine physician, a dietician and a clinical psychologist. Between 2017 and 2019, 425 individuals were trained as Health Peers. This study aims to determine the impact on dietary and exercise behaviour on residents who received peer coaching. A total of 65 residents were recruited and monitored for two months. The Health Peers conducted the coaching sessions during home visits or at Senior Activity Centres. Residents reported on the frequency of their exercise and dietary habits. Data was collected at baseline, one month into health coaching, and two months into health coaching.
Each resident received a total of 4 coaching sessions in the form of phone calls and/or house visits over two months. During the coaching sessions, the Health Peers supported residents by facilitating them to set and achieve their goals to improve their lifestyle habits.100% of residents reduced their frequency of sweetened drinks of which 49.2% reported that they did not consume sweetened drinks in a week at 2-month compared to 29.2% at baseline. Improvements were also observed in consumption of fruits from baseline to 2-month with 61.5% of residents having fruits daily at 2-month compared to 52.3% at baseline. Self-reported weekly exercise level increased from 72.3% of residents exercising at least once a week at baseline to 93.8% at 2-month. Average weight of residents also decreased from 63.4kg to 62.8kg. Findings from this study suggest that community-based peer coaching can be effective in improving lifestyle habits and provides evidence for the promising potential of the Health Peers Programme as a community resource in the prevention and management of diabetes.
Presenting Author: Dr Susheel Joginder Singh, Universiti Kebangsaan Malaysia
The Use Of Augmentative and Alternative Communication System by Children with Developmental Disability in the Classroom
Augmentative and alternative communication (AAC) systems serve as the primary mode of communication for many children with complex communication needs. In Malaysia, more and more children with developmental disability are being introduced to AAC. As attending school is an essential part of these children's life, it is important that they use AAC to communicate in schools. This study aimed to describe the nature of use of AAC by students with developmental disability in the classroom. Six students were observed and six hours of video recordings obtained for each student. The video recordings were transcribed then coded for the presence of a communication event, communication partner involved, student's mode of communication and communication function, and access to the AAC system. The students primarily communicated with gestures despite having an AAC system. It was found that nearly half of the time, the students' AAC system was not within an arm's reach. When student communicated with their AAC system, they mainly interacted with the teachers and the primary function served was behavioural regulation. Contrary to past studies, these students spontaneously initiated almost as many times as they responded. Results from this study indicated that more effort is needed to make sure that students have constant access to and opportunity to use their AAC system.
Presenting Author: Lee Rui Jia, Sengkang General Hospital
Empowering Nurses to Enhance Nutritional Care at Home
Patients discharged from hospital may face nutritional issues at home including malnutrition, tube feeding problems and poorly managed chronic diseases, which may result in complications and hospital readmissions. In the Sengkang General Hospital (SKH) Hospital-to-Home (H2H) program, Patient Navigators (PN) provide home care support to patients discharged from SKH. SKH Dietetics developed a two-module Nutrition Home Care Training Program (NHCTP) to equip PNs with basic nutritional knowledge to address common nutritional issues at home and escalate suitable patients to dietitians. This study aimed to evaluate the effectiveness of this training program. Nutrition knowledge quizzes were administered to PNs before and after each module to assess the change in the knowledge scores. PNs completed a post-training questionnaire with a 5-point Likert scale to evaluate the program's usefulness (1 = not useful; 5 = very useful), PN's confidence in addressing nutritional issues and identifying patients who require further dietitian input (1 = not confident; 5 = very confident), and reported change in nutritional knowledge (1 = no change in knowledge; 5 = very significant increase in knowledge). Among the 5 PNs who completed the NHCTP, mean knowledge scores improved for each module (1st module: 50% to 85%, 2nd module: 36% to 88%). Overall, PNs found the training useful (mean = 4). They also reported increased knowledge of common nutritional feeds (mean = 3.8), interpreting tube feeding regimen (mean = 3.8), and dietary management of chronic diseases (mean = 3.8). After the training, they were more confident in answering simple nutrition questions from patients (mean=3.8) and escalating suitable patients to dietitians (mean = 4.6). SKH Dietetics NHCTP has shown to improve PN's knowledge and confidence in addressing nutritional issues at home after discharge. With increasing focus on moving care beyond hospitals into the community, extending NHCTP to community partners can ensure seamless nutritional care and patient safety.
2) Future Ready Workforce
Presenting Author: Jeremy Koh, Singapore General Hospital
The Hard Truth About Soft Skills - Exploring the Association between Leadership Competency and Career Advancement
Globally, employee engagement in healthcare organisations is low, and one of its main determinants is the dimension of career advancement. It may be useful for healthcare organisations to determine the factors of career advancement, so as to guide them to more effectively engage their workforce. Leadership competency is factor that may play a crucial role in influencing the career advancement for employees in healthcare organisations. To our knowledge, a comprehensive analysis on its impact on the perception of career advancement within the healthcare setting has not been conducted. This study aimed to examine the association between leadership competency of healthcare professionals and perceptions of career advancement. An ecological, cross-sectional study was conducted. Poisson generalized-estimating equation models were fitted to estimate the adjusted rate ratios with bootstrap 95% confidence intervals for the associations of the AHEAD items with the number of favourable responses on the career advancement items. In each model, we accounted for clustering by AHD departments and controlled for length of service as a confounder. Statistically significant predictors of perception of career advancement were found, and included skills such as Interpersonal Skills (aRR 1.53 CI 1.12 to 2.96), Motivating (aRR 1.31 CI 1.10 to 2.16), and Mentoring (aRR 1.30 CI 1.08 to 1.13); and values such as Compassion (aRR 1.37 CI 1.17 to 3.40), and Collegiality (aRR 1.31 CI 1.00 to 1.99). Our findings show an association between some components of leadership competency and the perception of career advancement. These results provide initial evidence that apart from hard skills, soft skills may play an equally (or more important) role in influencing the perception of career advancement.
Presenting Author: Peh Hui Peng, Singapore General Hospital
Telepractice adoption in speech and language therapy during COVID-19: Benefits and challenges
Past surveys on telepractice show high interest but low uptake of this service delivery mode amongst speech therapists in India and Hong Kong. Yet the underlying barriers and clinicians' experiences in adopting telepractice are not well understood. The COVID-19 pandemic has accelerated the adoption of telepractice in allied health services over in-person sessions, especially during the Circuit Breaker (CB) period. Our study aims to understand the perceived value, barriers and benefits of telepractice by Speech Therapists (STs) in Singapore, particularly during their transition to conform with CB restrictions. We conducted a cross-sectional survey of STs in Singapore through convenience sampling. Survey responses were electronically captured and analysed using descriptive statistics. Responses to open-ended questions were thematically analysed. Among the 114 STs practising in Singapore who completed the survey, 67.5% provided telepractice services during CB period. Of these, 72.7% reported changes in their use of telepractice due to CB restrictions, including starting telepractice, increasing the frequency and range of caseload in telepractice. There was an increase in STs providing telepractice services in most practice areas, most markedly in the areas of developmental language (+122.2%) and social communication disorder (+104.8%). Key perceived benefits of telepractice were: 1. Easy access to services (94.7%), 2. Timely continuity of care (79.8%), 3. Increased frequency of therapy (69.3%), and 4. Client participation within a familiar environment (69.3%). Operational advantages included ease of scheduling sessions (43.9%) and time efficiency (42.1%). Majority of STs (76.3%) believed that in-person therapy is of better overall quality. 82.5% felt in-person visits were more appropriate for their clients, with 95.6% regarding their clients (e.g. young children, those with swallowing difficulties) unsuitable for telepractice. Other perceived barriers were clients' lack of access to technology, therapists' lack of resources, and clients' and therapists' lack of understanding and negative opinion of the efficacy of telepractice. While telepractice ensures continuity of care where in-person care is disrupted, barriers exist in its application across all areas of speech therapy practice. Adequate support must be provided for speech therapists and their clients to ensure that quality of care is maintained despite the change in therapy delivery mode.
Presenting Author: Tan Li Li, Singapore Polytechnic
Work-Based Learning (WBL) Model To Develop Self-Directed Learning Skills in Optometry Education – An Evaluation
Introduction. This paper evaluated the effectiveness of work-based learning (WBL) model to develop self-directed learning skills in optometry education. Methods. 'WBL cohort 1' in Academic year (AY) 1819S1 (n = 20) and 'WBL cohort 2' in AY1920S1 (n = 65) were studied and compared with a 'traditional cohort' (n = 42). The following were investigated: (i) student survey (SS); (ii) focus group interview (FGI); (iii) adjunct lecturer survey and (iv) final module score (FMS) in four core modules. Results. Through SS, > 60% reported that WBL enabled them to be self-directed learners and > 80% felt that it helped to develop useful optometry skills and knowledge. Through FGI, 83% of the 'WBL cohort 1' and 54% of the 'WBL cohort 2' reported that it trained them to be self-directed learners. More than 60% of the adjunct lecturers surveyed reported that WBL had exhibited good interpersonal skills, critical thinking and good traits of an independent optometrist. However, these were not as clearly evident when the cohort size was increased. Based on academic performance (with FMS as an indicator), WBL produced variable results in the four core modules surveyed, with WBL cohorts 1 and 2 performing differently. Conclusion. WBL model was able to develop self-directed learners and professional dispositions as well as generic employability skills. To scale WBL for larger cohorts, considerations must be given to faculty and resource availability, which it demands. Keywords: Work-based learning, self-directed learning, optometry, workplace.
Presenting Author: Yap Ai, National University Hospital
Effectiveness of Therapy Support Associates (TSA) in providing Rehabilitation for patients who underwent Total Knee Replacement (TKR) surgery in National University Hospital
There is a projected disproportionate increase in the demand for Physiotherapy as Singapore's population greys. Therapist Support Associate(s) (TSA) may reduce this demand by seeing these cases independently, following instructions from the Physiotherapist (PT). We examined the effectiveness of including a TSA in the outpatient post-operative care of patients who had undergone Total Knee Replacement (TKR). 48 patients participated in this randomised controlled trial. The control group received physiotherapy as usual. For participants allocated to the TSA group, PT-in-charge assessed and treated on the first session and then after every two sessions with the TSA. TSA supervised two sessions based on the PT's plan. Patients were seen weekly in both groups. The study was concluded by the 12th week following the first visit. Outcomes measures were taken on the first session and by the 12th week by a blinded assessor. The outcome measures were: active and passive knee range-of-movement (ROM), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Patient Specific Functional Scale (PSFS) for sit-to-stand and 10-minute walking. Statistical analysis on the outcome measures was performed using repeated measures ANOVA. There was no difference in the outcomes measures between Control & TSA groups except for passive extension ROM. Patients in the control group achieved greater improvement in passive extension range, 5.5 degree compared to 0.8 degree (p = 0.024). In conclusion, the introduction of TSA to post-operative Physiotherapy care of patients who had undergone TKR did not adversely affect patient recovery as demonstrated by the similar outcomes of the WOMAC, PSFS for sit-to-stand and 10-minute walking. Active and passive flexion ROM and active extension ROM were also similar. A greater emphasis by the treating PT to the TSA on passive knee extension may help ameliorate the difference in the passive range achieved. Therefore, the inclusion of TSA in patient care should be considered. This would expand the capacity of PTs to treat more patients while freeing up PT resources for more complex cases.
3) Health Services Research
Presenting Author: Jasly Koo, KK Women's and Children's Hospital
Impact of a standardised nutrition protocol on malnutrition rate in newly diagnosed children with cancer
Malnutrition in children with cancer, defined as weight loss of > 5% in the first 6 months post-diagnosis, is related to higher mortality and infection rate. Serial nutritional assessments throughout treatment are recommended to prevent malnutrition but consensus is lacking in terms of intervention timing and frequency. Hence, this study aimed to evaluate the impact of a standardised nutrition protocol on reducing malnutrition rate compared to a historical cohort.
This was a pre-post study of newly-diagnosed children with cancer (2 to 17 years old) in January to December 2015 (control group, n=53) and March 2017 to April 2019 (intervention group, n=61). The control group received ad-hoc dietetic interventions based on medical assessments. The intervention group received a standardised nutrition protocol, which comprised of malnutrition assessment using Subjective Global Nutrition Assessment by dietitian at diagnosis, tiered dietetic intervention based on nutritional status and regular time-point reviews. Proactive malnutrition screening upon admissions were also conducted by nurses who flag up high-risk patients for timely interventions. Data on demographics, diagnosis and treatment modalities were obtained. Primary outcome was incidence of malnutrition at 6 months post-diagnosis. Analyses were conducted using descriptive and logistic regression. Both groups did not differ significantly in terms of age at diagnosis, gender, treatment modality and baseline body mass index Z-score. A higher proportion of patients in the intervention group received oral nutritional supplements on advice of dietitian (pre: 11/39 (28.2%), post: 14/59 (76.3%), p<0.05). The proportion of patients with malnutrition at 6 months post-diagnosis was significantly lower in the intervention [11/59 (18.6%)] than control group [16/39 (41.0 %), p= 0.021]. After adjusting for age, treatment modalities and cancer type, the intervention group had a significantly lower risk of malnutrition at 6 months (adjusted odds ratio: 0.30 (95% CI: 0.12 to 0.79), p= 0.014).The results demonstrated that a standardised nutrition protocol reduced malnutrition rate. The early malnutrition assessment individualised the intensity of our interventions to optimise our resources without compromising patient care. Targeted screening facilitated timely intervention and ensured patients' nutritional status is not neglected. Further evaluation is required to determine the most appropriate interval for interventions.
Presenting Author: Dr Beron Tan, KK Women's and Children's Hospital
The effects of early screening and intervention on psychosocial outcomes in Singaporean children with cancer and their parents
Research has indicated the need for early monitoring of psychosocial functioning in children with cancer and their parents. A comprehensive psychosocial screening programme for children with cancer in Singapore was developed. This study evaluated the effectiveness of early screening and intervention on psychosocial outcomes in children with cancer and their parents. The programme included psychosocial screenings conducted in the first year of cancer diagnosis at 0-month, and every quarter of the year. Psychological intervention was provided by clinical psychologists to children and parents who were identified as psychologically distress through the screening protocol. This case-controlled study prospectively recruited 62 children and their main caregiving parent into the psychosocial programme; the control group was based on 52 children and parents recruited retrospectively before the programme was implemented. Psychosocial outcomes were based on 1) psychological distress and 2) health-related quality of life (HRQoL) questionnaires collected at one year following the cancer diagnosis for both prospective and retrospective groups. There were no significant group differences in psychological distress and HRQoL in children with cancer (p > .05). Additionally, the HRQoL did not differ significantly for parents in both groups (p > .05). Nevertheless, there was a significant difference in psychological distress between parents of both groups, ꭓ2(1) = 6.73, p <.01, and the effect size is moderate, Cramér's V = .35. Specifically, the odds of psychological distress were 11 times greater in parents from the retrospective group compared to parents in the prospective group. Indeed, 31% of the parents in the retrospective group were in psychological distress, compared to 4% of the parents in the prospective group after 1 year into the cancer diagnosis. Early psychosocial screening and intervention in the first year of childhood cancer was effective in reducing psychological distress, particularly for parents. Nevertheless, more targeted support may be required to address the complex psychosocial needs of children with cancer in the early stage of treatment.
Presenting Author: Muhammad Isa Bin Mohd Musa, National Heart Centre Singapore
Effects of the Enhanced Recovery after Thoracic Surgery Pathway on Post-Operative Outcomes
Enhanced recovery after surgery (ERAS) pathways have shown to be effective in reducing hospital length of stay (LOS) and postoperative complication rates. Early mobilization is also recommended as it has been reported to be safe and feasible. In National Heart Centre Singapore (NHCS), the physiotherapists and doctors have initiated the Enhanced Recovery after Thoracic Surgery (ERATS) pathway where we target to improve patients' outcomes – reduction in LOS, pain, and complications and enhance early recovery. Based on a selection criteria, suitable patients recruited into this pathway will be mobilized on post-operation day (POD) 0. The aim of this service audit is to evaluate the feasibility of early mobilization on POD 0 in NHCS and study the effects of the ERATS pathway on post-operative outcomes. 75 patients who had thoracic surgeries done from June 2020 to September 2020 were analyzed, of which 21 were recruited under the ERATS pathway. Quality of recovery was measured using the Quality of Recovery–15 Questionnaire (QoR-15) on POD 1 and before discharge. The number of days required for a patient to achieve functional independence (FI) i.e. where patient is able to perform bed mobility and ambulation tasks without assistance, was also recorded. LOS, 30-day readmission rates and any adverse events during physiotherapy sessions on POD 0 were other outcomes that were tracked. The physiotherapists successfully mobilized 86% of the ERATS patients on POD 0. Three patients did not mobilize due to giddiness and pain symptoms. Zero adverse events were recorded. Patients on the ERATS pathway had a 14% shorter LOS and required 18% less time to achieve FI than those who were not. A 2% higher improvement in QoR-15 score was observed in patients on the ERATS pathway. Four thoracic surgery patients were readmitted within 30 days, of which only one was under ERATS pathway. Early mobilization on POD 0 in patients undergoing uncomplicated thoracic surgery is safe and feasible. The ERATS pathway demonstrated improvements in postoperative outcomes. However sample size is small and will require further evaluation.
Presenting Author: Nadiah Binte Mohamed Rahim, National Heart Centre Singapore
Frailty Assessment in patients undergoing Transcatheter Aortic Valve Implantation (TAVI)
The presence of frailty is often associated with poor outcomes and functional recovery after a surgery. The aim of the study is to analyze the prevalence of frailty, by assessing physical frailty score, functional independence, gait speed, hand grip strength, cognitive function and quality of life (QoL) prior to TAVI implantation and whether the six domains improved after surgery. This is a retrospective review of patients referred for frailty assessment as part of TAVI workup from April 2016 and April 2018. Frailty assessments were conducted by physiotherapists at baseline and 3-months post TAVI. Physical frailty was assessed using the Clinical Frailty Scale (CFS). Functional dependence was measured using the Katz Index and Lawton Brody Scale. Gait speed using the 5 Metre Walk Test (5MWT) and hand grip strength were used as outcome measures for physical functioning. Cognitive function was assessed using the Mini - Mental State Examination (MSSE) questionnaire. To assess QoL, patients were asked to self-rate their health. Frailty cut-off scores for each domain were also defined. Chi-square test was used for comparison between baseline and 3-months frailty scores. Post TAVI, all patients received multidisciplinary care, including inpatient physiotherapy rehabilitation, as well as, advice on activity and exercise guidelines prior to discharge. Fifty-four patients had both baseline and 3-months frailty assessments performed. Gait speed (X2 = 6.834, p <0.009) and self-rated health questionnaire (X2=17.28, p=0) were found to be statistically significant. At baseline, 54.9% were considered frail based on their 5 MWT results and only 7.4 % rated their health as very good and excellent. In contrast, at 3 months post TAVI, the percentages improved to 35.2 % and 22.2% respectively. Based on the self-rated health questionnaire, 86.3% of the patients rated their QoL to be at least somewhat better as compared to before TAVI implantation. Aside from handgrip strength, there were improvement for the other five domains after TAVI implantation. Significant improvements were found in gait speed and self-rating of health. This provides meaningful information with respect to interdisciplinary care management aim at improving physical, cognitive, functional independence and quality of life.
4) Innovation & Digital Strategies
Presenting Author: Lim Su Lin, National University Hospital
Effect of a Diabetes Lifestyle Intervention using Technology Empowerment (D'LITE) in Individuals with Type 2 Diabetes: A Randomized Clinical Trial
Introduction: Lifestyle interventions are effective in diabetes management, with smartphones gaining popularity as a delivery mode. However, limited evidence from randomised clinical trials (RCTs) exists regarding the effectiveness of smartphone-based interventions among overweight or obese Asians with type 2 diabetes. The objective of the study was to compare the effects of a culturally adapted smartphone-based intervention with usual care on weight and metabolic outcomes.
Methods: Adults with Type 2 Diabetes and body mass index ≥ 23 kg/m2 were randomised to control group of standard care (diet and lifestyle advice) or intervention group (diet and lifestyle advice + Nutritionist Buddy Diabetes app, a form of virtual care). Body weight, HbA1c, fasting blood glucose, food diary and diabetes medication information were collected at baseline and 6 months.
Results: Of the 305 adults screened, a total of 204 patients (105 control, 99 intervention) were recruited for the study. The intervention group experienced significantly greater weight loss (3.6 kg vs 1.2 kg; p<0.001), percentage of weight loss (4.3% vs 1.4%; p<0.001), reduction in HbA1c (0.7% vs 0.3%; p<0.001) and fasting blood glucose (0.8 mmol/L vs 0.1 mmol/L; p=0.001), compared to the control group. Among participants with HbA1c ≥8%, the intervention led to a greater HbA1c reduction (1.8% vs 1.0%, p = 0.001). A significantly greater proportion of intervention participants had their diabetes medications reduced compared to control participants (23.3% vs 5.4%, p = 0.02). The changes in medications led to a reduction in annual costs of both diabetes medications in the intervention group, and an increase in annual costs of medications in the control group, with significant differences between groups. The intervention group had greater reductions in calorie, carbohydrate and sugar intake at 6-month compared to the control group (p<0.001 for all).
Conclusions and Implications: A smartphone-based lifestyle intervention was more effective in achieving weight and glycemic reductions among Asians with type 2 diabetes compared to usual care, indicating a potential for smartphone use in intervention delivery. This modality of intervention is potentially scalable to serve the larger population.
Presenting Author: Dr Lim Rou Wei, Singapore General Hospital
Learning how to safely escape from sugary situation
Introduction: Escape room is increasingly used as an innovative educational tool to engage learners in healthcare. The immersive nature of escape room environment allows learners to engage in active learning, utilize teamwork, communication and critical thinking skills to complete tasks within a stipulated timeframe. Education in diabetes management was conventionally delivered using didactic lectures. To reinforce pharmacists' understanding about medication safety and importance of teamwork, communication and critical thinking skills, our faculty developed a low-cost and engaging educational tool on diabetes management using escape room concept.
Methods: In the escape room, pharmacists worked in teams to complete a series of tasks related to medication safety issues in diabetes management, focusing on unsafe practices and preventable medication errors. The scenarios were adapted from actual medication safety cases. Pharmacists investigated the preventable cause(s) of patient's death. They identified practice gaps leading to medication errors, determine appropriate management of hypoglycemia, insulin conversions, titrations and administration. A post-game debrief was conducted to foster self-reflection and consolidate learning objectives. Pharmacists completed pre- and post-activity assessments on diabetes management and survey using Kirkpatrick evaluation framework.
Results: Thirty-seven pharmacists, with 1 to 5 years of acute care practice, participated and successfully "escape" the room within 60 minutes. For Kirkpatrick Level 1, a median of 98.7% (78.4%–100%) chose "strongly agreed"/"agreed" that the educational game was effective. Compared to conventional teaching, pharmacists found the game an effective way to learn new information and reinforce existing knowledge through their interaction as a team. For Kirkpatrick Level 2, a median of 97.3% (90.2%-100%) chose "strongly agreed"/"agreed" that they learnt skills in critical thinking, clinical practice, communication and teamwork. The top 3 learning points that pharmacists could apply at work were (i) insulin conversion and titration, (ii) insulin administration and (iii) awareness of preventable medication errors. The pre- and post-assessment scores in knowledge on diabetes management were 80% and 90%, respectively. The expenditure for game setup was SGD$98.00.
Conclusion: The escape room is a low-cost and engaging educational tool that effectively facilitate the training and assessment of pharmacists' knowledge about preventable medication errors, teamwork, communication and critical thinking skills.
Presenting Author: Ng Khim Siong, SingHealth Polyclinics
Study on the Effectiveness of Musculoskeletal Pain Educational Programme on Pharmacists' and Pharmacy Technicians' Learning
Introduction: Patients often receive conflicting information about their musculoskeletal (MSK) pain despite their strong desire for clear, consistent and individualised information on this medical condition. An e-lecture on MSK pain which includes pain biology and management strategies was developed to educate healthcare professionals so that consistent information on this medical issue can be conveyed to the patients. This study aimed to evaluate the effectiveness of a single 1-hour e-lecture conducted by an experienced physiotherapist in improving pharmacy staff's understanding of MSK pain.
Methods: This randomised multi-centre, prospective study was conducted across 8 polyclinics. Pharmacy staff working in the polyclinics were invited to participate in the study. Participants in both the intervention and control groups were asked to complete the validated 12-question Neurophysiology of Pain Questionnaire (NPQ) twice. The intervention group completed the NPQ immediately before and after the e-lecture while the control group completed the NPQ twice at 1 hour apart. The intervention group was also asked to complete a self-developed 5-question survey form to assess their perceived understanding and interest to the e-lecture. The anonymised data collected was analysed using descriptive and inferential statistics.
Results: A total of 64 participants with a mean age of 36.0 ± 13.3 years completed the study.
The study found that the control group's NPQ score prior to and after the lecture were 6.3 ± 2.6 and 6.3 ± 2.7 respectively while that in the intervention group were 6.3 ± 2.7 and 8.7 ± 2.4 respectively. The intervention group's NPQ score was 2.4 ± 0.6 points higher than the control group, with a 95% CI of 1.2 to 3.6 (p=0.00). Participants who attended the e-lecture felt that the lecture was interesting (7.8 ± 1.5, out of a total score of 10) and easy to understand (7.7 ± 1.5). They felt they gained new knowledge from the lecture (8.0 ± 1.5). They also find the lecture helped them to understand MSK pain (7.9 ± 1.5) which is useful to their work (7.8 ± 1.6).
Conclusion: The 1-hour e-lecture is effective in improving pharmacy staff's knowledge on MSK pain.
Presenting Author: Woon Ee Lin, Singapore General Hospital
Rehabilitation recovery application to support self-monitoring after anterior cruciate ligament reconstruction
Introduction: Following an anterior cruciate ligament reconstruction (ACLR), empowering patients as active agents in their rehabilitation requires them to monitor their recovery in knee flexion range-of-motion, quadriceps strength, and knee self-efficacy. Given the ubiquity of mobile phones, it is advantageous to provide functional recovery curves in the form of a web application which allows patients to gain easy access. A review of the existing literature, however, suggests that trajectory curves of these knee measures remain poorly defined. Thus, this study aimed to (i) describe, in a large ACLR cohort, knee flexion range-of-motion, quadriceps strength, and knee self-efficacy trajectory curves over the initial 6-months post-surgery and (ii) develop a web application that generates the trajectory curves by patient and surgical factors.
Methods: A total of 595 patients with unilateral ACLR (mean age, 27 years) participated in this longitudinal study. At 2-, 3-, and 6-months post-surgery, knee flexion range-of-motion, quadriceps strength, and knee self-efficacy were quantified. Sports activity levels were assessed using the Tegner Activity Score at 6-months post-ACLR. Multivariable generalized least squares regression was used to generate trajectory curves for the measures, stratified by patients' Month-6 Tegner score.
Results: The various knee measures improved nonlinearly over time, with substantial improvements observed in the first 2 to 4 months post-surgery. In multivariable models, greater knee flexion range-of-motion, quadriceps strength, and knee self-efficacy over time were significantly associated with higher Month-6 Tegner scores (all P values<0.01). Additionally, receiving a bone-patellar-tendon-bone graft or meniscal repair was associated with lower quadriceps strength trajectories (P-values<0.001) while female sex was associated with lower knee self-efficacy trajectories (P=0.02). To personalize this information, an interactive website was created (https://sghpt.shinyapps.io/alpha/) where trajectory curves can be explored in detail based on individual demographics, anthropometric, and surgical measures.
Conclusion: We are amongst the first to present detailed trajectory curves to facilitate post-ACLR functional recovery tracking. We found a graded association between Month-6 Tegner scores and improvements in knee flexion range-of-motion, quadriceps strength, and knee self-efficacy over time. The trajectory curves and web-based application developed from this study could improve patient communication and education, potentially allowing patients to take charge of their rehabilitation.
1) Beyond Hospital Walls
Presenting Author: Candy Chan Hiu Nam, Sengkang General Hospital
Makan Away Frailty - An Innovative Board Game to Empower Singapore Seniors with Nutrition Knowledge to Combat Frailty
Frailty is a common geriatric syndrome that is preventable and reversible. Good nutrition is one of the key tactics to help combat frailty. Nutrition education delivered via one-way nutrition talks is common but not effective in engagement and empowerment. This traditional approach may not be sustainable, especially in the community setting due to cost, limited manpower, language barriers and diverse motivational and educational levels among seniors. Therefore, the Dietetics Department of Sengkang General Hospital has collaborated with the SingHealth Institute for Patient Safety & Quality since 2018 to design an innovative board game – Makan Away Frailty, targeted at the silver generation to empower them with nutrition knowledge to combat frailty. Makan Away Frailty is an educational board game for seniors to learn the healthy eating principles to combat frailty by incorporating four food groups from My Healthy Plate in their diet with the emphasis of having adequate protein and calcium intake. It comprises of 6 pieces of cardboard with food photos and 104 food cards with recommended serving and calcium content. The 3-phase Design Thinking methodology has been adopted to design the game tailoring to the needs and perspectives of the seniors and the staff from Senior Activity Centres (SACs). Understand Phase: Three ethnographic observations were done at 1 SAC, followed by interviews conducted before and after a nutrition talk with 16 seniors and 3 SAC staff. The key findings related to effective education included 1) peer learning, 2) short sessions 3) pictorial presentations due to fleeting memory, poor hearing, low vision and language barriers, 4) unawareness of habitual unhealthy eating pattern and 5) less confident with modern technologies. Explore Phase: The team held brainstorming sessions to identify potential improvement measures to address the gaps identified in the 'Understand Phase'. A non-digital game-based approach was identified to be effective in stimulating peer learning and social interactions. The Bloom's Taxonomy was applied to divide learning objectives into 2 levels: "remembering" via playing the game and "understanding" via food cards. Test Phase: A prototype was piloted in 3 SACs, followed by interviews with the seniors to validate the concept and design elements. Pre-and post-knowledge quizzes were also conducted to understand the effectiveness of the game in nutrition knowledge empowerment. Based on gathered feedback and quiz results, the prototype was enhanced with improved quality and size of food photos, increased number of common food options and additional trilingual nutritional information. The Design Thinking approach allowed us to develop a senior-centered educational game through the following key elements: visible photo size, food photos instead of graphics to allow real life association, minimal use of words and cognitively challenging experiences to build confidence. These identified elements in this board game allow the multi-racial seniors in Singapore to learn nutrition knowledge to combat frailty in an effective and enjoyable way. Makan Away Frailty in an innovative, engaging, cost-effective and sustainable board game which can be easily applied in the community setting to engage and empower seniors to combat frailty through playing.
Presenting Author: Jenny Loo Hooi Yin, National University Hospital
The development of community audiology service in Singapore
Community-based audiology service is considered new to the Singapore healthcare landscape. Access to audiology service was traditionally limited to the public healthcare institutions (PHIs), with a mandatory visit to the Ear Nose Throat (ENT) specialists before seeing an audiologist. With the increasing demand for hearing intervention due to our growing aging population with hearing loss, it is inevitable that the wait time for audiology service in PHIs rises quickly. This creates a constant battle to the audiology departments in PHIs to keep patient wait time low, yet not exhausting the team and resources. To curb patient wait time, the only possible solution is to increase service accessibility at the community level. This presentation will share and discuss the development of community audiology service in Singapore in the past 5 years, from building mobile hearing clinic (MHC) to setting up satellite hearing clinic (SHC), championed by the audiology team from the National University Hospital (NUH). Unlike other allied health services, duplicating audiology service outside the hospital comes with hefty cost and unique challenges due to its soundproofing requirement. Hearing assessment requires precision of sound measurement at the ear level in a quiet room that meets international acoustical standard. Therefore, the conceptualisation of MHC in 2015 took a tremendous effort and expertise, by converting a 24-footer long container into a gigantic soundproof booth that is mounted on a truck chassis. Since the provision of MHC, it has benefited more than 12,000 patients island-wide. Although MHC serves the objective of providing high quality hearing assessment and management at the residents door steps, there are considerable non-audiological efforts involved. Securing a safe and spacious carpark, sourcing for electricity power supply from adjacent building, troubleshooting equipment at off-site without ITD support, are some examples that are not commonly encountered by audiologist working in a hospital. Learning a great deal from the operation of MHC over the past few years, the team ventured into a new hearing care delivery model in mid of 2020. The setting up of a SHC without a soundproof booth is a complete novelty. The implementation of hearing test in a non-soundproof booth is a collaborative effort with the NUS Audiology research team, which has enabled the provision of community-based audiology service more easily and cost saving. Although this non-soundproof testing method offers full potential for diagnostic and reliable test value, a subset of patients with specific ear conditions (e.g. impacted ear wax, ear discharge) may deem unsuitable and will require conventional testing method. In a nutshell, there are pros and cons of the different delivery models (MHC versus SHC) for a community-based audiology service in Singapore. Service provider needs to carefully access the population needs and the long term operational cost of each model to provide a sustainable healthcare system in Singapore.
2) Future Ready Workforce
Presenting Author: Koh Sei Keng, Singapore General Hospital
Developing Pharmacists for a VUCA world
The role of pharmacy and pharmacists in healthcare is evolving as technologies like artificial intelligence (AI) and virtual health drive disruptions and transformative changes. AI and machine learning will create new insights, while robotics and automation will change the way prescriptions are processed, dispensed and delivered. The role of telehealth and virtual healthcare will expand further. This fluid environment is commonly described as VUCA – volatile, uncertain, complex and ambiguous. As the pharmacy continues to use enabling technologies, pharmacists will need to reflect on their roles in the healthcare value chain. In this narrative, we share our journey to build a future ready workforce. In 2019, two separate HMDP visiting expert programmes were conducted to review the workforce development initiatives. The visiting experts engaged with various key stakeholders, performed situational analysis and provided recommendations for strategic planning. Through one of these programmes, the Development Framework for Pharmacists (DFP) was conceived by forming the continuum of competency from foundation to advanced practice. The DFP aimed at facilitating a systematic and harmonized progression to develop pharmacists of enhanced capability in eight key roles – care provider, collaborator, communicator, health advocate, leader, manager, educator and researcher-innovator. Through the DFP, the required competencies underpinning the development of the eight key roles were identified. The multiple roles will enable pharmacists to diversify by acquiring multiple skillsets. This approach allows pharmacists to build resilience and adaptability in the face of the VUCA world. To promote change, we need a vision, on top of developing skills, incentives, resources and action plans. We envisioned an adaptable workforce, with multiple roles and able to provide care wherever patients are. Pharmacists will continue to be recognized as the drug experts, advocate for health and wellbeing of residents, and care providers for patients with chronic or complex diseases. There would also be increasing roles with focus on mental health, promoting behavioral changes through health coaching and addressing the social determinants of health to improve care. The DFP was launched in May 2020 to articulate skill sets for development. Training resources such as the portfolio building and assessment workshops are ongoing to equip pharmacists with the basic skills to embark on the DFP. Stakeholders engagements are ongoing to gather buy-in and to co-create solutions for overcoming challenges faced. The pharmacy career track review will be conducted with key stakeholders' input to ensure alignment of the envisioned roles with appropriate resources allocation. Action plans would be developed upon weighting of priorities across levels. The implementation of DFP requires focused and continued stakeholder engagements with strong support by pharmacy leadership. A person-centric approach is critical to ensure sustainability of efforts towards achieving the objectives of the development framework. The importance of communication tools as sources of truths are key to ensure clarity of the vision and purpose. Finally, effective monitoring parameters needed to be put in place and communicated for tracking of progress.
Presenting Author: Lim Hui Shan, Singapore Polytechnic
Online Simulation Clinic in Optometric Education during COVID-19 Pandemic
The Singapore Polytechnic (SP) Diploma in Optometry (DOPT) course aims to produce professionally competent optometrists. The Singapore Polytechnic Optometry Centre (SPOC) is set up to provide the students with the real-world, and application-based training, through seeing patients while under the supervision of a lecturer. Due to COVID-19 pandemic, the circuit breaker measures were imposed from April to June 2020, and all lessons had to be held online. The biggest challenge faced was on how to provide clinical training for students virtually. The clinical training in SPOC was converted into online simulation clinic (OSC), aimed to provide similar training as SPOC through case studies. Case studies with clear learning outcomes were delivered over video conferencing platforms. During each session, a group of 6-8 students will work with one lecturer on a case over two weeks. The role of the lecturer is to facilitate and role-play as the patient. The students work together as one optometrist to see the patient, and they are assigned to one of the following roles: conduct history taking, develop possible diagnoses, identify significant findings, suggest further investigative tests, provide patient management plan and act as the scribe. At the end of each case, students were assigned a topic that is related to the case to research on, to enhance and deepen their learning, and the findings were presented in the following week. A total of 54 students rated 4.02 out of 5 for their overall experience with OSC. 89% of the students felt that OSC was well organized with clear objectives, 97% found the cases manageable and relevant to their work in future, 93% felt engaged during OSC, 96% enjoyed learning from peers during case discussion and benefited from the feedback from lecturers, and 83% found the post-OSC assignment to be beneficial for their learning. The student's performance on communication skills was compared between before implementation of OSC and after implementation of OSC. The students performed better after the implementation of OSC in history taking (p<0.0001) and patient management (p=0.022). The COVID-19 pandemic has led to the development of OSC, an innovative yet effective way to provide communication and problem-solving skills training virtually. The students also found the OSC experience to be very positive, and the activities were engaging, manageable and beneficial to learning. However, there is a need to explore alternative ways to provide hands-on clinical skills virtually. As clinical training in SPOC is a very resource-demanding and patient-dependent programme, OSC has shown the possibility to develop students' communication skills effectively without the need for extra resources and safely amid a pandemic. OSC can be incorporated into the existing clinical training programme at SPOC, which supports the training of hands-on clinical skills, to supplement the communication and problem-solving skills.
Presenting Author: Chong Ai Jia Letty, Singapore General Hospital
Discovering the Unknown; Radiographer Reject Rate Analysis
Radiographs that are rejected by the radiographer without being sent for reporting are called rejected images. The amount of rejected images produced by each radiographer is required to calculate individual radiographer's reject rate. Reject analysis helps guide the education and training of staff, influences department workflow, and reduces patient doses. Reject rate analysis (RRA) relies on the exported logs from the modality workstation, sorted out by the reasons for rejection and normalised by the total number of acquisitions made during the period. However, the modality workstations fail to capture radiographers' initials leading to a large amount of unknown data. This resulted in an incomplete and uncomprehensive RRA. The aim of the quality improvement (QI) project is to decrease the number of unknown data from Singapore General Hospital (SGH) general radiography modality workstations by 90% within 8 months. The root cause of the problem was analysed using the 5 Whys technique. The root cause was attributed to the radiography department not having the expertise to configure the system to gather information on unknown data. Fuji engineer was engaged to configure the workstations to allow the extracted log to contain examination details. A centralized excel spreadsheet using visual basic applications (VBA) was created and the link using IP addresses of the workstations were established. This allowed the data to be extracted remotely through the VBA spreadsheet. The spreadsheet was tested in SGH campus and subsequently extended to other off-campus imaging centres. The extracted raw data can be mapped with the Radiology Information System (RIS) to identify the unknown data, causing a 100% reduction in the number of unknown data seen across the workstations within SGH and other off-campus imaging centres. As data can be extracted remotely, it resulted in zero footsteps needed to extract the data. It also shortened the time taken to extract the data from one week to five minutes. This contributed to an estimated amount of $20, 607.53 of manpower saving per annum. The ease of data extraction allows the audit process to be much smoother. The data extracted contains other useful information that can be further analyse and develop other training or education strategies for the radiographers' professional development. The framework showed considerable potential in long-term sustainability and can be implemented to other institutions. It can also be adopted by other vendors for the ease of data transfer and identification. The reduction of unknown data lead to an increased accuracy of the radiographers' RRA. This allows identification of training and learning gaps for the radiographers. Targeted training and education of radiographers can be planned to facilitate producing of radiological images of good diagnostic quality. This minimizes unnecessary radiation dose given to patient and value adds to the patient's diagnosis and care.
Presenting Author: Benjamin Chow, Changi General Hospital
Time-motion analysis for productivity
Background: Changi General Hospital speech therapists (ST) were keen to examine the impact of the following factors on productivity:  Validity of referral and  actual clinical time utilization. Resolving the issue: A time motion study was embarked to determine the duration to complete specific tasks involved in case management. These tasks include both direct and indirect patient activities. Face to face (F2F) activities are interactions with patients during assessment and therapy. Non-F2F activities include resource preparation and documentation. Data was collected across 15 weeks from inpatient, outpatient and emergency department services. ST had to log each activity on an Excel template using their mobile phones. The data was analysed using data science coding language, R. The results were published on a dashboard, which was subsequently presented to the department. Findings including  validating referrals did not significantly affect productivity, contrary to the department's belief.  The median duration for F2F activities was a third of the time spent in managing cases. Patient charges may need to be reviewed to reflect this time spent.  A breakdown of non-F2F activity identified documentation as a modifiable factor, which could be streamlined to increase efficiency. Lessons learnt: Real time data collection is more accurate than retrospective data. It is more detailed than data binned into 30-minute intervals, which allows for accurate evaluation of time spent. Detailed data was also useful for exploratory data analysis. The collection of real time data was possible using the Excel template. The simplicity and availability of Microsoft Excel highlights the point that it is about selecting the most appropriate technology rather than the trendiest technology. Significance to the department: The project helped removed the negative perception of "time wastage" for inappropriate referrals as this was not shown to be of significance. It also justifies more accurate charging for a better reflection of ST's clinical time utilisation. Additionally, it resulted in streamlining of documentation. A time motion study allows for more accurate workload optimisation and appropriate resource allocation. Real time data entry allows for prediction of trends and more meaningful analysis of operations and workflow.
4) Innovation & Digital Strategies
Presenting Author: Liew Yoke Fun Selina, Changi General Hospital
The Implementation of an Electronic Communication Board (E-board) to streamline workflow processes for breast imaging patients
Effective communication across different imaging modalities and disciplines is paramount to ensure a streamlined workflow. At our breast imaging department, a prompt and accurate update of patient statuses and waiting time is essential to allow a smooth handover of patients with different imaging requirements. Our multi-disciplinary breast imaging team consists of radiologists, breast surgeons, radiographers, nurses, healthcare assistants and administrative staff. The work processes involve handling of scheduled requests, as well as ad hoc studies requested by the reporting radiologist. As such requests are unpredictable but yet time-sensitive, this complicates routine handling of patients' multiple scheduled appointments. Three main strategies were used to help navigate through the challenges. Firstly, patients were given a "Patient Updating Chit" (PUC) that could be updated whenever a procedure was added or completed. Secondly, a manual communication board in the form of a whiteboard was placed in the radiologists' reporting room, allowing for an overview of the patients' statuses. Thirdly, for additional requests, radiologists filled up a Request Sheet (RS) which would be passed to the radiographers by the healthcare assistant. However, the above-mentioned strategies brought about their own set of challenges. Patients often misplaced their PUCs, or a team member who couldn't leave his/her station would be unable to update the communication board promptly. The delay created confusion among team members. Moreover, the healthcare assistant had to walk back and forth to pass over the RS, on top of her duties of assisting patients in the waiting area. Due to frequent delays and miscommunication despite these efforts, patient complaints were common occurrences and these inadvertently created tension among team members. Eventually, our team came up with the idea of having an Electronic Communication Board (E-board) that could serve all goals of the three above-mentioned strategies with significantly less hiccups. Well thought-out categories, icons and colours were used to highlight important information quickly, and updating could be done remotely with ease. Additionally, our Radiological Information System (RIS) and Queue Management System (One-Queue) also play important roles in patient management. Our E-board enhances their roles as it allows input of important information which were not reflected in these systems. The initial platform for the E-board was on Google Chrome, which we later switched to our hospital internal network platform to heighten cyber security and connection stability. Only healthcare providers who were granted access to the E-board would have the rights to view and edit the document. The implementation of our E-board has greatly improved workflow efficiency and communication. All in all, it has streamlined patient management and elevated overall staff satisfaction. The combined effort of our team members in working towards the common goal of resolving challenges has also brought everyone closer together, igniting the team spirit in our breast imaging department.
Presenting Author: Kek Tze Ling, National University Hospital
Transforming Audiological Care: From Clinic to Home
The concept of telehealth has been established for years, but not until recently that it has gained much attention due to the global outbreak of COVID-19 pandemic. Many allied health services have incorporated telehealth as one of the viable options to ensure continual patient care; Audiology is one of them. Teleaudiology comes with its unique challenges that are not met in other allied health services, as its serviced population has hearing impairment. This paper will share 1) the transformation of hearing care services that are typically conducted behind the door of a sound proof room to the patient's home, 2) the benefits of teleaudiology to patients, and 3) professional learning points. The usual hearing care delivery model starts from a diagnostic hearing assessment in a sound proof room, to providing hearing intervention through amplification devices and aural rehabilitation (therapy). It is a procedural intensive clinical service that relies heavily on test equipment. Every session lasts about 60 to 90 minutes depending on the type of procedures. Typically hearing impaired patient's journey involves at least 5 clinical visits before the individual would comfortably be fitted with hearing aid (HA). Hence, the team carefully crafted out procedures (sessions) that can be done remotely through technology, with the aim to reduce patient's visit to hospital, yet maintaining the quality of care. One of the aforementioned procedures that is turned into a telehealth practice is consultation for hearing aid, or known as hearing aid evaluation (HAE). A traditional HAE session involves both counselling and technical hearing aid trial. The counselling part involves explanation on patient's hearing profile and its implication on communication, description on function and limitations of hearing devices. It is important for establishing patient's realistic expectation as well as the commitment required for successful hearing intervention. Hearing aid trial part involves the selection of suitable hearing aid models and on-the-spot trial. Majority of the patients would adopt hearing aids after the trial, but some might be reluctant to proceed due to some personal concerns or having to discuss with family members. With the implementation of tele-HAE, the counseling part is now conducted remotely at the convenience of patient's home, with family members joining the online meeting to better understand patient's hearing needs and care. Only patients who are keen for adopting hearing aids after the teleHAE session will be given an appointment in clinic for hearing aid trial. This process has helped to reduce patient wait time, by not subjecting every individual to go through the same process of 90min traditional HAE session. To further promote teleaudiology, patient's hearing aid package is delivered to their home with remote fine-tuning done through mobile phone apps, which conventionally has to be done in clinic. Teleaudiology has indeed given patients greater access and flexibility to manage their hearing needs. The success of teleaudiology requires much efforts in preparation for the session and a mindset change among the community of audiologists.
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