Our Quality Commitment

Acute Myocardial Infarction Indicators

Acute Myocardial Infarction (AMI), a subset of Ischaemic Heart Disease (IHD), is the second leading cause of death in Singapore in 2021[1]. AMI or 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 2022 to December 2022 was 97.8%, which is above the 2019 National Benchmark of 95.6%.

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 2022 to December 2022 was 98.8%, which is above the 2019 National Mean of 97.2%.

References:

1. Ministry of Health > Statistics > Singapore Health Facts > Principal Causes of Death 2021
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 Percutaneous 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 (Endophthalmitis)

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 some degree of vision impairment from a cataract in Singapore. As we age, some of the proteins in the lens of our eye clump together and start to cloud the lens and form a cataract. Cataracts can also form at an earlier age in people with certain diseases (e.g., diabetes), on certain medications (e.g., steroids), or after trauma. Cataracts can reduce the sharpness of the image reaching the retina, add a brownish tint to one’s vision, worsen night vision or cause glare.

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

Endophthalmitis is a vision threatening infection of the eye that can occur after cataract surgery, and the incidence worldwide ranges from 0.08% to 0.68%. Hence, it is crucial that the hospital and patient takes precautions to reduce the chances of this infection occurring. Over a 10-year period (2013 to 2022), the incidence of endophthalmitis after cataract surgery in KTPH for our unit was 0.004% (1 in 25,477).

References:

1. American Academy of Ophthalmology (2021). Preferred Practice Pattern Guidelines: Cataract in Adult Eye. https://www.aao.org/education/preferred-practice-pattern/cataract-in-adult-eye-ppp-2021-in-press.
2. National Eye Institute, U.S. Department of Health and Human Services (2023). Cataracts. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts.
3. Endophthalmitis. https://eyewiki.aao.org/Endophthalmitis.
4. 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.

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)

Turbinoplasty is a procedure done to relieve nasal congestion. It can also be done along with FESS and Septoplasty, to treat obstructive sleep apnoea. 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 2022 to December 2022, 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 2022 to December 2022, the mean rate of secondary haemorrhage following tonsillectomy is 3.4% (n=1), which is below 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

The World Health Organization 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, physiological and psychological state, medical history, as well as extrinsic causes such as poor lighting, wet floor, floor has obstacles, inappropriate footwear 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 2022 to December 2022, the average incidence was 1.03 inpatient falls per 1000 patient days, which is comparable when benchmarked with the national falls prevention indicators (National average of 0.90 falls per 1,000 patient days in 2020)

From January 2022 to December 2022, the average incidence was 0.03 inpatient falls with major injury per 1000 patient days.

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) between January 2022 to December 2022 is about 0.19%. This is below the incidences of 1 to 5%1 as quoted by several international studies. About 40% of these recovered completely.

References:

1. White Paper on Third Molar Data 2007. American Association of Oral and Maxillofacial Surgeons