Our Quality Commitment

Acute Myocardial Infarction Indicators

Acute Myocardial Infarction Indicators Acute Myocardial Infarction (AMI), one of a subset of an Ischaemic Heart Disease (IHD), is the third leading cause of death in Singapore in 2016[1]. AMI better known as heart attack occurs when blood flow to the heart is blocked or reduced causing the heart tissue to die. Risk factors such as smoking, diabetes, elevated cholesterol, high blood pressure and obesity increases the risk of a heart attack.

Perfect Care Indicator

'Perfect Care' for AMI patient is an evidence-based treatment guideline introduced by McLeod Health that has been recognised by international health authorities in US and Australia. KTPH has incorporated the ‘Perfect Care’ guideline and has set it as one of our quality of care improvement initiatives. AMI patients are considered to have received ‘Perfect Care’ when they have received the following care elements, unless contra-indicated:

1. Early administration of aspirin
   
2. Aspirin at discharge
   
3. Statin at discharge
   
4. Beta blocker at discharge
   
5. Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blockers (ARB) for left ventricular systolic dysfunction (LVSD) at discharge
   
6. Timely administration of thrombolytics or percutaneous coronary intervention (PCI)
7. Smoking cessation counselling
   

The average rate from January 2020 to December 2020 is 98.0%, which is comparable to the 2019 National Benchmark of 97.2%.

Percutaneous Coronary Intervention within 90 Minutes of Hospital Arrival Indicator

Among the seven care elements in our Perfect Care Indicator, timely administration of Percutaneous Coronary Intervention (PCI) is closely monitored to ensure that time-critical treatment is delivered to AMI patients. PCI is a non-invasive procedure performed to open blocked coronary arteries and to restore blood flow to the heart tissues. A special catheter (small tube), with a tiny balloon at its tip, is inserted into the blocked artery. The balloon is inflated and compresses the fatty tissues blocking the artery, allowing a larger opening and thus improving the blood flow to the heart tissues.

This time-critical treatment is measured by the ‘door-to-balloon’ time. The internationally adopted gold standard as established by the American College of Cardiology and the American Heart Association for the ‘door-to-balloon’ time is 90 minutes or less [4]. The average rate from January 2020 to December 2020 is 98.1%, which is comparable to the 2019 National Mean of 95.5%.

References:

1. Ministry of Health > Statistics > Singapore Health Facts > Principal Causes of Death 2016
2. Ministry of Health, Singapore, Public Hospital Performance Report 2020
3. American Heart Association: Recommendations for Criteria for STEMI Systems of Care, updated 2016
4. UK Myocardial Ischaemia National Audit Project (MINAP), 13th Annual Report, 2014
5. Moscucci, M and Eagle, K. A. (2006). Door-to-Balloon Time in Primary Precutaneous Coronary Intervention: Is the 90-Minute Gold Standard an Unreachable Chimara? Circulation, 113, 1048-1050. Doi:10.1161/ CIRCULATIONAHA.105.606905

Post-operative Infection after Cataract Surgery

A cataract is a cloudiness of the normally clear lens in the eye. Cataract is common among the elderly and over 80% of people aged 60 years old and above have vision impairment from a cataract in Singapore. As we age, some of the proteins in the lens of our eye may clump together and start to cloud the lens. Cataract is often a progressive age-related condition. Cataract can reduce the sharpness of the image reaching the retina, add a brownish tint to one’s vision or cause glare.

Cataract is detected through a comprehensive eye examination, including a visual acuity test and dilated eye exam. The only effective treatment for cataract is surgery. The primary indication for surgery is when the patient’s reduced vision affects his/her ability to perform daily activities (e.g., driving or reading). Cataract surgery involves the removal of the clouded lens and replacing it with a lens implant. Although cataract surgery is generally safe, it carries the risk of bleeding and infection as with other types of surgical procedures.

Endophthalmitis is a vision threatening infection of the eye that can occur after cataract surgery. Hence, it is crucial that the doctor takes precautions to reduce the chances of this infection occurring. From January 2020 to December 2020, there were no cases of endophthalmitis in our patients who had undergone cataract surgery done by our staff.

References:

1. American Academy of Ophthalmology (2016). Preferred Practice Pattern Guidelines: Cataract in Adult Eye.
2. National Eye Institute, U.S. Department of Health and Human Services (2015). Facts about Cataract.
3. Chua J et al. Ancestry, socioeconomic status, and age-related cataract in Asians: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology 2015 Nov;122(11):2169-78.

Incidences of Extravasation

Extravasation is defined as the leakage of an injected medicinal solution from a vein into the surrounding tissues beneath the skin.

There are many factors leading to extravasation and they are mainly related to the device (undesirable cannulation site), drug (blister causing), patient (small and fragile veins) and the way the drug is injected. Early signs and symptoms include persistent burning or stinging pain, as well as rashes at the injected site. Extravasation may result in skin infection, functional impairment and extended hospitalisation, occasionally also requiring surgical cleansing or skin grafting.

At KTPH, our staff are vigilant in ensuring that patients do not have extravasations and take necessary precautions in dealing with patients at a high risk of extravasation. From January 2020 to December 2020, the mean extravasation rate was 0.09%, which is lower than international standards (0.44%, Canada, 2012).

References:

1. Clinical guidelines for Extravasation and Infiltration, Berry K. (2017), Great Ormond Street Hospital, UK
2. Study of patients with intravenous contrast extravasation on CT studies, with radiology staff and ward staff cannulations, Kingston, R. J., Young, N., Sindhusake, D.P., and Truong, M. (2012). McMaster University, Canada, Journal of Medical Imaging and Radiation Oncology, 56(2), 163-167.
3. What are Current Recommendations for Treatment of Drug Extravasation?, Jennifer A. (2015), University of Illinois at Chicago, US

Functional Endoscopic Sinus Surgery (FESS)

FESS is a minimally invasive procedure to unblock the sinus openings into the nose resulting in a decrease of discharges, pain and pressure. A small camera is placed into the nose and with specialised surgical instruments, the sinus openings are enlarged to facilitate drainage.

Septoplasty

Septoplasty is performed to correct a deviated nasal septum (bone and cartilages separating the two nostrils). An incision is made to remove parts of the septum before it is straightened and repositioned to the middle of the nose. This procedure will help relief nasal blockage.

Inferior Turbinectomy (IT)

Turbinectomy is a procedure done to relieve nasal congestion. It can also be done along with FESS and Septoplasty, to treat obstructive sleep apnea. The inferior turbinate, consisting of soft tissues and bones, is prone to swelling causing obstruction. It is reshaped and trimmed to improve breathing through the nose.

Bleeding after FESS, Septoplasty, and IT

As with any surgeries, FESS, Septoplasty and IT carries risks, such as bleeding. The Department of Otolaryngology (ENT) takes all precautions and measures to minimise bleeding post-surgery. From January 2020 to December 2020, there were no cases of bleeding after FESS, septoplasty, and IT, which is comparable to international rates of 0.5%¹.

References:

1. Complication rates after Functional Endoscopic Sinus Surgery: Analysis of 50,734 Japanese Patients (Laryngoscope 2015;125:1785-1791)
2. Postoperative Bleeding after diathermy and Dissection Tonsillectomy (Laryngoscope 2005;115:591-4)
3. About Functional Endoscopic Sinus Surgery (FESS) by Gerry McGarry, ENT UK, 2015
4. About Septoplasty Care at Mayo Clinic, US, 2018
5. Mehrzad, H., Irvine, M., & Bleach, N. (2007). A 5-Year Audit of Rhinology Procedures carried out in a District General Hospital. Ann R Coll Surg Engl, 89(8), 804-807. doi: 10.1308/003588407X209275
6. Zapanta, P. E, & Khoury, T. (US, 2016). Turbinectomy.

Secondary Haemorrhage following Tonsillectomy

Tonsils are two oval-shaped pads of tissue located at the back of the throat. Tonsillectomy is then the surgical term used to describe the removal of the tonsils. Infected or enlarged tonsils may lead to chronic or recurrent sore throat, bad breath, abscess, airway obstruction, difficulty in swallowing and snoring. This procedure helps to reduce infection and inflammation of the tonsils which is known as tonsillitis, as well as to resolve breathing problems. Like any other surgeries, this procedure has risks such as bleeding can occur in the first 24 hours following the operation (primary), or later (secondary).

KTPH maintains a high vigilance on its quality of surgical techniques and management of patient after Tonsillectomy. This indicator serves to reduce patients’ risk through active monitoring of post-tonsillectomy bleeding complications. From January 2020 to December 2020, the mean rate of secondary haemorrhage following tonsillectomy is 11.1% (n=1), which is comparable to the international rates of 10%.

References:

1. About Tonsillectomy, Mayo clinic, US, 2018.
2. Mersch, J. (2017). Tonsillectomy and Adenoidectomy Surgical Instructions.
3. Laryngoscope 2005;115:591-4. Postoperative Bleeding after Diathermy and Dissection Tonsillectomy

Prolonged Stay in Post-anaesthesia Care Unit (PACU)

The post-anaesthesia care unit (PACU) provides close monitoring and care to patients who have undergone procedures requiring the use of various types of anaesthesia. In PACU, specially trained nurses, supported by doctors, will closely track the vital signs of the patients, manage their pain, and assess their surgical site for possible issues such as excessive bleeding. Besides observing and monitoring, the PACU is the point where pain-relieving measures are continued from the operating room. Patients are educated on the use of Patient Controlled Analgesia (PCA) to self-manage their pain.

The prolonged stay in PACU (defined as > 2 hours) due to complications arising from anaesthesia and surgery is a surrogate measure of the quality of anaesthesia care given to our patients. KTPH has implemented initiatives to comfort patients by keeping them warm and administer medications for pain and nausea. Our average rate from January 2020 to December 2020 was 0.06%.

References:

1. Important Complications of Anaesthesia, by Dr Gurvinder Rull, 2014
2. Post-Anaesthesia Care Unit, The Ottawa Hospital, Canada, 2016.

The World Health Organisation defines a fall as “an involuntary event resulting to a rest on the ground, floor or other lower level”. There are many factors contributing to a fall, including intrinsic causes such as patient’s age, psychological state, medical history, as well as extrinsic causes such as poor lighting, wet floor, floor has obstacles, inappropriate foot wear and inappropriate mobility aid.

The undesirable consequences from a fall may lead to physical injuries such as bruising, fractures as well as psychological and social effects. This is known as the ‘post-fall syndrome’, which is the constant fear of a repeated fall, and may cause the victim to disengage in daily activities and thus affecting their quality of life.

In KTPH, we have implemented a comprehensive falls assessment, intervention and education program. Some of these measures include identifying patients as high risk using bright green wrist tags and good practices such as regularly addressing patients’ personal and toileting needs and incorporating safety features in the design of our environment. Physiotherapists and Occupational Therapists including other allied health professionals are an integral part of the multidisciplinary team who contribute to risk assessment and falls prevention program in the hospital and maintain functional independence.

Family members and caregivers are educated on falls risk prevention and they are encouraged to follow safe behavioural practices such as putting up cot sides and informing the nurses prior to leaving after visiting. The family members are also encouraged to accompany confused and restless patients during their stay in the hospital.

Annual Falls Awareness Day is held to engage public in understanding the falls risk and prevention measures, and provide necessary resources available in the community to reduce falls in the community.

From January 2020 to December 2020, the mean incidence of inpatient falls per 1000 patient days was 0.97 which is when benchmarked is comparable with national falls prevention indicators (National benchmark of 0.87 falls per 1,000 patient days in 2018, and 0.93 per 1,000 patient days in 2019).

References:

1. How do you measure fall rates and fall prevention practices? January 2013. Agency for Healthcare Research and Quality, Rockville, MD. National Database of Nursing Quality Indicator (NDNQI)
2. World Health Organization, Media centre, Falls, Fact sheet, reviewed Jan 2018.
3. Ministry of Health, Singapore, NSHC Self-Assessment Indicators for Public Hospitals and Institutions, 2018
   

The third molars are commonly referred to as the wisdom teeth. Their failure to erupt into the mouth often causes infection in the gums and food trap leading to decay, pain and swelling. Wisdom teeth extractions are the most common surgeries performed by dental surgeons. In our Dental Centre, more than 50 wisdom teeth are removed daily!

Inferior Dental Nerve Paraesthesia After Lower Third Molar Surgery

One of the risks of wisdom teeth surgery is the potential injury to the inferior dental nerves. The inferior dental nerve provides sensation to the chin, lower lip and teeth in the lower jaw. Injury to this nerve can result in the temporary or permanent, partial or complete loss in sensation in the areas supplied by the nerve.

The degree of risk is in part dependent on the anatomical location of the nerves in relation to the wisdom tooth. A clinical examination with x-rays is necessary to provide an indication of the potential of such an injury.

In KTPH, the average incidence of post-operative inferior dental nerve paraesthesia recorded at first postoperative review (about 7 to 10 days after the operation) from January 2020 to December 2020 is about 0.39%. This is comparable to several studies citing incidences of 1 to 5% ¹ . A reduction in the incidence may imply an improvement of surgical technique, while an increase in incidence may mean an increase in the complexity of cases presented to the clinic. About 40% of these recovered completely.

Post-operative Infection after Lower Third Molar Surgeries

Infection after wisdom teeth surgery can develop in the early or late post-operative period. In KTPH, the average rate of incidence of post-operative infection following wisdom teeth surgeries from January 2020 to December 2020 is about 0.07%. Post-operative infection rates reported in the literature range from 0.8% to 4.2% ² .

References:

1. White Paper on Third Molar Data 2007. American Association of Oral and Maxillofacial Surgeons
2. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral and Maxillofacial Surgery Clinics of North America 2007 Feb: 19(1):117-28

Benign prostatic enlargement is a common problem among men over 55 years old. The prostate gland is located around the outlet of the bladder, and thus its enlargement can obstruct the flow of urine, giving rise to symptoms like slow urine flow, sense of incomplete emptying, urgency and frequency.

The gold standard surgical treatment for benign prostatic enlargement is a Transurethral Resection of the Prostate (TURP). TURP is a minimally invasive procedure which removes the obstructing part of the prostate and restores the width of the urinary channel for good urine flow. In the past, bleeding during TURP was a common problem, which resulted in a frequent need for blood transfusion during operation. The significant bleeding also limited the surgeons’ view to do a thorough job in resecting the obstructing prostate.

Many technical advances in the last few decades have made TURP a safe procedure that is suitable for the majority of patients suffering from prostatic enlargement. An example is the bipolar resection technology, which allows much better bleeding control during TURP, minimising blood loss and safely increasing the operative time limit for the surgeon to do a thorough resection.

The Department of Urology in Khoo Teck Puat Hospital has utilised this bipolar resection technology as a routine practice for our patients undergoing TURP, as we believe that we should only offer the safest options to our patients. To date, we have performed TURP for hundreds of patients with excellent clinical outcome. Severe bleeding incidences are highly unlikely and the requirement for blood transfusion has been kept to a minimum. From January 2020 to December 2020, the mean rate was 1.3% (n=1), which is at the lower range of what is quoted in current international literature³ (up to 4%).

References:

1. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, N'dow J, Nordling J, de la Rosette JJ; European Association of Urology. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013 Jul;64(1):118-40
2. Shum CF, Mukherjee A, Teo CP. Catheter-free discharge on first postoperative day after bipolar transurethral resection of prostate: clinical outcomes of 100 cases. Int J Urol 2014 Mar;21(3):313-8
3. Da Silva RD, Bidikov L, Michaels W, Gustafson D, Molina WR, Kim FJ. Bipolar energy in the treatment of benign prostatic hyperplasia: a current systematic review of the literature. Can J Urol 2015; 22(Suppl 1):30-44