Innovative Patient Safety Curriculum Using iPAD Game (PASSED) Improved Patient Safety Concepts in Undergraduate Medical Students.

INTRODUCTION: While healthcare outcomes have improved significantly, the complex management of diseases in the hospitals has also escalated the risks in patient safety. Therefore, in the process of training medical students to be proficient in medical knowledge and skills, the importance of patient safety cannot be neglected. A new innovation using mobile apps gaming system (PAtient Safety in Surgical EDucation-PASSED) to teach medical students on patient safety was created. Students were taught concepts of patient safety followed by a gaming session using iPad games created by us. This study aims to evaluate the outcome of patient safety perception using the PASSED games created. METHODS: An interactive iPad game focusing on patient safety issues was created by the undergraduate education team in the Department of Surgery, Yong Loo Lin School of Medicine at the National University of Singapore. The game employed the unique touched-screen feature with clinical scenarios extracted from the hospital sentinel events. Some of the questions were time sensitive, with extra bonus marks awarded if the student provided the correct answer within 10 s. Students could reattempt the questions if the initial answer was wrong. However, this entailed demerit points. Third-year medical students posted to the Department of Surgery experienced this gaming system in a cohort of 55-60 students. Baseline understanding of the students on patient safety was evaluated using Attitudes to Patient Safety Questionnaire III (APSQ-III) prior to the game. A 20 min talk on concept of patient safety using the WHO Patient Safety Guidelines was conducted. Following this, students downloaded the apps from ITune store and played with the game for 20-30 min. The session ended with the students completing the postintervention questionnaire. RESULTS: A total of 221 3rd year medical students responded to the survey during the PASSED session. Majority of the students felt that the PASSED game had trained them to understand the processes of medical error (p < 0.001), that their understanding on patient safety issues improved (p = 0.007), and the training prepared them to prevent medical errors (p < 0.001). Many students also recognized the importance of error reporting, where they felt comfortable reporting errors committed by themselves (p < 0.001) or by other people (p < 0.001). They also felt comfortable discussing with the supervisor on medical errors (p < 0.001). Students responded that better teamwork will reduce medical errors (p = 0.003), and teaching teamwork skills will reduce medical errors (p = 0.002). After the PASSED session, students felt that patients could play an important role in preventing medical errors (p < 0.001). They felt that patient safety should be emphasized in undergraduate training (p = 0.024). The level of understanding about concepts of patient safety was also found to improve progressively from the 2nd posting to the 5th posting for both the pre-PASSED and post-PASSED intervention. The pre-PASSED scores for Posting 2 (3.59 ± 1.931), Posting 3 (4.11 ± 1.833), Posting 4 (4.84 ± 1.653), and Posting 5 (4.88 ± 1.642) were significantly higher than the post-PASSED scores for Posting 2 (4.46 ± 2.020), Posting 3 (5.17 ± 1.845), Posting 4 (5.88 ± 1.843), and Posting 5 (5.80 ± 1.843), respectively (p < 0.001). CONCLUSION: Using iPad game (PASSED) to enhance the patient safety teaching has successfully improved the awareness and understanding of patient safety in clinical practice. This training model can be used to teach more senior medical students on the complexity of patient safety issues in medicine.

CT volumetry of the liver: where does it stand in clinical practice?

Imaging-based volumetry has been increasingly utilised in current clinical practice to obtain accurate measurements of the liver volume. This is particularly useful prior to major hepatic resection and living donor liver transplantation where the size of the remnant liver and liver graft, respectively, affects procedural success and postoperative mortality and morbidity. The use of imaging-based volumetry, with emphasis on computed tomography, will be reviewed. We will explore the various technical factors that contribute to accurate volumetric measurements, and demonstrate how the accuracies of these techniques are influenced by their methodologies. The strengths and limitations of using anatomical imaging to estimate liver volume will be discussed, in relation to laboratory and functional imaging methods of assessment.

Is pancreaticoduodenectomy justified in elderly patients?

BACKGROUND: Although mortality & morbidity for pancreaticoduodenectomy (PD) have improved significantly over the last two decades, the concern for elderly undergoing PD remains. This study examines the outcome of the elderly patients who had pancreaticoduodenectomy in our institution. METHODS: A prospective database comprising 69 patients who underwent pancreaticoduodenectomy between 2001 and May 2008 was analyzed. Using WHO definition, elderly patient is defined as age 65 and above in this study. Two groups of patients were compared [Group 1: Age ≤65 & Group 2: Age >65]. RESULTS: The mean age of our patients was 62 ± 11 years. There were 37 (54%) patients in Group 1 and 32 (46%) patients in Group 2. There was no statistical difference between the two groups in terms of gender and race. However, there were more patients in the Group 2 with >2 comorbidities (p = 0.03). The median duration of operation was significantly longer in Group 2 (550 min vs 471 min, p = 0.04). Morbidity rate in Group 2 was higher (56% vs. 44%, p = 0.04). There was higher proportion of post-operative pancreatic fistula (POPF) in the elderly group (37.5% vs. 16.7%, p = 0.05). Majority of them are Grade A POPF according to the ISG definition. The median post-operative length-of-stay (LOS) in hospital was 9 days longer in Group 2 (p = 0.01). Mortality rate between the 2 groups of patients was comparable (0% vs. 3%, p = 0.28). CONCLUSION: Elderly patients are at increased risk of morbidity in pancreatocoduodenectomy, in particular POPF. However, morbidity and mortality rates are acceptable. It is therefore justified to offer PD to elderly patients who do not have significant cardiopulmonary comorbidities.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen.

BACKGROUND: Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery. METHODS: We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech(®)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists. RESULTS: There were 4 patients with a median age of 50 (43-69) years. The median duration of the condition prior to PTCSL was 102 (60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130 (125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18 (10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up. CONCLUSION: PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique.

Striving for a better operative outcome: 101 pancreaticoduodenectomies.

Pancreaticoduodenectomy (PD), once carried high morbidity and mortality, is now a routine operation performed for lesions arising from the pancreatico-duodenal complex. This study reviews the outcome of 101 pancreaticoduodenectomies performed after formalization of HepatoPancreatoBiliary (HPB) unit in the Department of Surgery. A prospective database comprising of patients who underwent PD was set up in 1999. Retrospective data for patients operated between 1996 and 1999 was included. One hundred and one cases accrued over 10 years from 1996 to 2006 were analysed using SPSS (Version 12.0). The mean age of our cohort of patients was 61+/-12 years with male to female ratio of 2:1. The commonest clinical presentations were obstructive jaundice (64%) and abdominal pain (47%). Majority had malignant lesions (86%) with invasive adenocarcinoma of the head of pancreas being the predominant histopathology (41%). Median operative time was 315 (180-945) minutes. Two-third of our patients had pancreaticojejunostomy (PJ) while the rest had pancreaticogastrostomy (PG). There were five patients with pancreatico-enteric anastomotic leak (5%), three of whom (3%) were from PJ anastomosis. Overall, in-hospital and 30-day mortality were both 3%. The median post-operative length of stay (LOS) was 15 days. Using logistic regressions, the post-operative morbidity predicts LOS following operation (p<0.005). The strategy in improving the morbidity and mortality rates of pancreaticoduodenectomies lies in the subspecialization of surgical services with regionalization of such complex surgeries to high volume centers. The key success lies in the dedication of staffs who continues to refine the clinical care pathway and standardize management protocol.

Musculoskeletal melioidosis masquerading as diabetic amyotrophy.

A patient with musculoskeletal melioidosis masquerading as diabetic amyotrophy is described. A 43-year-old man presented with left thigh pain, fever, malaise and loss of weight. He had diabetes mellitus for six years. He was initially diagnosed with diabetic amyotrophy and was treated conservatively. Recurrence of symptoms prompted further investigations which revealed melioidosis of the left femur. Magnetic resonance imaging showed an enhancing subperiosteal collection. The diagnosis was confirmed by open biopsy and tissue culture. Acute treatment consisted of intravenous ceftazidime for 24 days and oral cotrimoxazole. The patient showed marked improvement clinically and biochemically. He was discharged with oral doxycycline and cotrimoxazole for three months. This disease is eminently treatable, but can be a diagnostic challenge when it presents in an uncommon site.