Room 421 May 15, 2019 oral abstract
Service Enhancement Presentation 09:00 - 10:15

Clinical Safety and Quality Service III

Spasticity Management to enhance functional recovery for patient with Stroke.
09:00 - 09:10
Presented by : Dora CHAN

Introduction

According to the Seven Brunnstrom Stages of Motor Recovery (Brunnstrom 1970), stroke patients go through stage of flaccidity to some spastic tone, marked spasticity and synergistic movements in the first 4 stages. At stage 5, spasticity fading with synergies gradually reduced and develop coordinated and complex movement and back to normal. However, it is the most challenging task for therapists to help stroke patients who have developed mark spasticity to revert to regain normal movement from adapted synergistic movements. Sunnerhagen et. al., 2016, reviewed some predictors of post stroke spasticity. Based on Neuro-IFRAH approach, Occupational Therapy in Kowloon Hospital has been working in previous years to prevent and reduce spasticity for patients with stroke. The application is from sub-acute to out-patient phases. It involve in/out patient phase patient and care taker education on handling and positioning for shoulder protection and spasticity risk factors, stratified treatment in early trunk control, facilitative upper limb training, application of flexor tone inhibitory splints and home programs.

Objectives

(1) To prevent and reduce severe spasticity development in stroke survivors. (2) To enhance better upper limb and self-care function for patients with stroke.

Methodology

A retrospective review of stroke outcome data from CDARS is compared for in and out patients in the period of 2016 to 2018. For cases who had received intensive OT training together with botox injection or TMS treatment by Rehab Specialist, a pre-test and post –test design was used to compare the efficacy of intervention in spasticity, upper limb function and self-care function.

Results & Outcome

The retrospective review of inpatient data showed significate different of Functional Independence Measurement (FIM) gain for stroke patients (p< 0.001) in 2014/15 (n=803) average gain is 8 while 2016 to 2018 (n=2869) FIM gain is 11.1. From 2016 to 2018 CDARS data, Functional Test of Hempilegic Upper Extremity (FTHUE) gained average 0.5 (in-patients), and average 2 (out-patients). The intensive OT anti-spasticity program was also collaborated with two intervention of TMS and Botox injection by our Rehab Specialist in Kowloon Hospital also reflected positive outcomes in terms of FTHU, FIM active, passive range of movement and spasticity.

 

 

Cross-functional Program: Improving Anti-Embolism Stocking Application in Neurosurgical Unit with Lean and Six Sigma Framework
09:11 - 09:20
Presented by : Mr. Chan Kwun Fai

Introduction

Lean and Six Sigma is widely used in healthcare system to improve quality of care. Proper Anti-Embolism Stocking (TED) application is crucial to avoid patients suffering from deep vein thrombosis as a result of immobility. The author adopted Lean and Six Sigma framework to enhance effective application of TED in Neurosurgical Unit, PWH.

Objectives

(1) To Identify the root causes of inappropriate application of TED (2) To make a sustainable improvement of TED application in Neurosurgical Unit.

Methodology

The Lean and Six Sigma framework included: (1) Define phase, a multidisciplinary team included neurosurgical nurses and physiotherapists was formed in Neurosurgical Unit, PWH. A project charter was created to set the goal and scope of the program. Literature review about updated TED usage and monitoring was done. (2) Measure phase, for assessing staff performance, physiotherapists were invited to conduct pre-audit in collaboration with a Six Sigma Leader (Author). Moreover, nurses' and supporting staff knowledge was assessed with questionnaire. (3) Analyze phase, members performed data and graphical analysis to identify the root causes which were inadequate training and staff knowledge. (4) Improve phase, training sessions on proper TED application were held by nurses and physiotherapists. The video of training session was shared on electronic mobile platform for easy retrieval. In addition, the post-audit of TED application and staff knowledge assessment were conducted. (5) Control phase, a control plan included new staff orientation, regular internal audits were established. To make the improvement more sustainable, signage was designed and posted up to increase staff and relatives' awareness. A video was produced for educating relatives on the usage and care of TED, which would be broadcasted during visiting hours.

Results & Outcome

200 samples were collected in pre-& post-audits respectively. “Toe stick out of inspection hole” and “wrinkles” were the two most common problems. The number of improper TED wearing dropped from 148 to 69 after staff sharing sessions (95%CI, p-value< 0.001, Chi-square test). The Overall Effectiveness improved from 0.26 to 0.65 (95%CI, p-Value< 0.001, paired t-test). The SIGMA level increased from 2.4 σ to 3 σ. Staff knowledge also increased significantly, with mean score increased from 5.9 to 8.8 (95% CI, p-value< 0.001, paired t-test).

 

 

Prevalence of Sarcopenia in Geriatric Day Hospital Ambulatory Patient and the Effects of 8-week Resisted Exercise Training to their muscle-related functions
09:21 - 09:30
Presented by : K M CHENG

Introduction

Sarcopenia is a common but always underestimated condition in elderly population. According to Asia Working Group of Sarcopenia (AWGS), Gait speed < 0.8m/s and/or Handgrip Strength with Male < 26 Kg and Female < 18 Kg and Skeletal Muscle Index (SMI) with Male < 7kg/m2 and Female < 5.7kg/m2 are classified as sarcopenia. Sarcopenia in elderly is a known predictor for future morbidity and mortality. Early detection and intervention with Resisted Exercise Training are needed to augment the muscle-related functions of the sarcopenia elderly.

Objectives

1. Analyze the prevalence of ambulatory community-dwelling elderly (unaided or one handed aids) sarcopenia in Geriatric Day Hospital (GDH) 2. Evaluate the effect of an 8-week Resisted Exercise Training on muscle mass and the muscle-related functions.

Methodology

Elderly who were able to walk independently in GDH from July 2018 to September 2018 were selected. Elderly with pacemaker and metal implant were excluded. Handgrip Strength and bio-impedance body muscles composition assessment including SMI were assessed. The muscle-related functions including Timed Up and Go Test (TUGT) and Berg Balance Scale (BBS) were assessed. They were divided into two groups. One group (conventional) attended the conventional PT training in GDH and the other group (RE) received an 8-week Resisted Exercise Training at GDH and home regime with log book. All participants received the pre assessment and post 8 weeks assessment.

Results & Outcome

Results: Among 39 elderly assessed, 54% (N=21) was classified as sarcopenia according to AWGS definition. 12 and 9 sarcopenia elderly were assigned to RE and conventional group respectively. After 8-week training, both groups (3 cases drop out in RE group) showed significant improvement in BBS (RE: p=0.0001; conventional: p=0.001; paired t-test). RE group showed significant improvement in BBS (p=0.034; independent t-test) compared to conventional group. Only RE group showed significant improvement in TUGT (p=0.007; paired t-test). There was no significant difference in SMI in both groups. Conclusion: The prevalence of sarcopenia in GDH is quite high but they are often overlooked. Resisted Exercise Training has shown to be more effective to improve the muscle-related functions. Public Implications: Early screening and intervention with Resisted Exercise Training help to augment the muscle-related functions of sarcopenia elderly.

 

 

Strategies to prevent catheter-associated urinary tract infection of patients undergo colorectal resection in the zero-tolerance era
09:31 - 09:40
Presented by : Choi Ping LAM

Introduction

Catheter-associated urinary tract infection (CAUTI) is a major cause of hospital-acquired infection. For the Surgical Outcomes Monitoring and Improvement Programme (SOMIP) database from July 2015 to June 2016, symptomatic urinary tract infection rate in different surgical teams under HAHO, the mean score was 2.5%. However, the score in our colorectal surgical team was 5%. Cases were all systematically reviewed. Total 240 cases with colorectal resection performed during the year and 12 cases were post-operatively diagnosed of CAUTI. It was found that majority of the patients were suffered from rectal cancer and intra-abdominal pelvic surgeries were performed. The indwelling catheter should be kept at least 3 to 5 days after operation in order to close monitor the urine output and prevent from dehydration.

Objectives

1.To reduce the rate of catheter-associated urinary tract infection of patients undergo colorectal resection 2.To improve the quality of urinary catheter care in the Department of Surgery

Methodology

In order to compare the difference outcomes for difference interventions, project team planned to conduct the program into two phases within 6 months. In Phase I, five comprehensive strategies would be implemented from October to December, 2017. And in Phase II, five strategies with one more intervention would be implemented from January to March, 2018. Phase I 1.Reinforce strict aseptic technique of catheterization 2.Stop the practice of changing urometer, provide training to healthcare supporting staff and audit the practice 3.Design and use a paper card reminder for daily review catheter maintenance 4.Involve patients and carers for indwelling catheter care during post-operative period 5.Using devices to keep catheter in place after insertion Phase II Using antimicrobial 100% silicone urinary catheter in bundle with five preventive CAUTI interventions

Results & Outcome

Total of 110 patients were recruited in the program. The duration of catheterization at the period of 1/4/2017 – 30/9/17 and 1/10/17 – 31/3/18 was compared. Patients with catheterization more than 4 days (Post-operative Day 3) on 1/4/17 – 30/9/17 were 61.5% but only 34.5% on 1/10/17 – 31/3/17. It has been decreased 27%. Besides, there were total 4 patients with CAUTI during phase I of study. The percentage of CAUTI was 3.5% which was decreased 1.5% compared with the data of SOMIP in 2016. And it was shown that zero case of CAUTI in phase II after using antimicrobal urinary catheter.

 

 

Implementation of Osteoporosis Phone Direct Enquiry Service (OPD-ES) to maintain good service quality in the context of increasing patient load
09:41 - 09:50
Presented by : Connie LOONG

Introduction

The volume of patients with osteoporosis has been increasing in recent years due to multiple reasons. The frequency of follow-up for old cases in Osteoporosis Clinic has lengthened from 24+/-3 weeks in 2013 to 34+/-2 weeks in 2016. Such a lengthening is also contributed by the advanced age of osteoporosis patients as travelling may sometimes be difficult. In order to maintain our service quality, a nurse-led program, the Osteoporosis Phone Direct Enquiry Service (OPD-ES) has been implemented since Nov 2017.

Objectives

1.To enhance service quality and continuity of care to patient with osteoporosis with lengthening follow-up duration; 2.To evaluate the effectiveness of OPD-ES

Methodology

OPD-ES functions as an active communication channel between patients, their carers and health care professionals. A direct hotline operated in office hours allows patients and carers to actively seek advices from healthcare workers concerning their disease management in between their routine follow-up sessions. After addressing the enquiries immediately over the phone, nurse clinics are arranged for patients requiring individual education or counselling. All enquiries concerning patients’ medical condition are discussed in case conferences with in-charge physicians. Ad-hoc medical consultation appointment is arranged if considered necessary by the physician. The effectiveness of the service was assessed by the number of cases who used the service, and number of ad-hoc follow-up sessions arranged. Reasons of phone enquiries were also analysed.

Results & Outcome

463 (94% female) patients attended Osteoporosis Clinic from Nov 2017 to Nov 2018. All were put on anti-osteoporotic agents (Denosumab: 234, 50.5%; Bisphosphonates: 211, 45.6%; Teriparatide: 16, 3.5%; and Strontium: 2, 0.4%). 237 (51.2%) patients and/ or carers used OPD-ES. Reasons of enquiries included use of anti-osteoporotic agents (143, 30.9%), issues related to dental complaints or procedures (65, 14.0%) and changes in medical condition (29, 6.3%). 54 (22.8%) patients were arranged for education and counselling in nurse clinic, and 25 (10.5%) patients required ad-hoc medical consultation (medication intolerance: 9; new fracture: 7; deranged renal function: 5; stroke: 2; dental issue related to bisphosphonate osteonecrosis of jaw: 2). OPD-ES functions effectively to enhance good service quality and maintain good continuity of care to patients with osteoporosis who have long follow up duration. The program also empowers patients and carers to participate actively in their disease management through the service.

 

 

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