Evidence-Triggers for Care of Patients with Cleft Lip and Palate in Srinagarind Hospital: The Tawanchai Center and Out-Patients Surgical Room.

Background: Cleft lip and palate (CLP) is a congenital anomaly of the lip and palate that is caused by several factors. It was found in approximately one per 500 to 550 live births depending on nationality and socioeconomic status. The Tawanchai Center and out-patients surgical room of Srinagarind Hospital are responsible for providing care to patients with CLP (starting from birth to adolescent) and their caregivers. From the observations and interviews with nurses working in these units, they reported that both patients and their caregivers confronted many problems which affected their physical and mental health. Based on the Soukup's model (2000), the researchers used evidence triggers from clinical practice (practice triggers) and related literature (knowledge triggers) to investigate the problems. Objective: The purpose of this study was to investigate the problems of care for patients with CLP in the Tawanchai Center and out-patient surgical room of Srinagarind Hospital. Material and Method: The descriptive method was used in this study. For practice triggers, the researchers obtained the data from medical records of ten patients with CLP and from interviewing two patients with CLP, eight caregivers, two nurses, and two assistant workers. Instruments for the interview consisted of a demographic data form and a semi-structured questionnaire. For knowledge triggers, the researchers used a literature search. The data from both practice and knowledge triggers were collected between February and May 2016. The quantitative data were analyzed through frequency and percentage distributions and the qualitative data were analyzed through a content analysis. Results: The problems of care gained from practice and knowledge triggers were consistent and were identified as holistic issues, including 1) insufficient feeding, 2) risks of respiratory tract infections and physical disorders, 3) psychological problems, such as anxiety, stress, and distress, 4) socioeconomic problems, such as stigmatization, isolation, and loss of income, 5)spiritual problems, such as low self-esteem and low quality of life, 6) school absence and learning limitation, 7) lack of knowledge about CLP and its treatments, 8) misunderstanding towards roles among the multidisciplinary team, 9) no available services, and 10) shortage of healthcare professionals, especially speech language pathologists (SLPs). Conclusion: From evidence-triggers, the problems of care affect the patients and their caregivers holistically. Integrated long-term care by the multidisciplinary team is needed for children with CLP starting from birth to adolescent. Nurses should provide effective care to these patients and their caregivers by using a holistic approach and working collaboratively with other healthcare providers in the multidisciplinary team.

Development and Monitoring the Key Performent Index of The Quality of Care for Patients with Cleft/Palate in Tawanchai Center and Out-Patient Surgical Room Srinagarind Hospital Thailand.

BACKGROUND: Cleft lips and cleft palates have the most incidences in the Northeast of Thailand (2.49/1,000 newborns). Cleft lips and cleft palates (CLP) can affect patients and families both physically and mentally. It takes critical long-term medical treatment starting when prenatal, newborn, and fully grown until 19 years old by a multidisciplinary team; therefore, it was effective to have collaboration with patients, families, and a multidisciplinary team in order to build up the same objective and create key performance index to monitor the treatment outcome also to develop the quality of care. OBJECTIVE: 1) to create the key performance index and 2) to develop the index system by using information technology. MATERIAL AND METHOD: After the research received ethics approval from Khon Kaen University, qualitative and quantitative data were collected. There were two periods in this study. The 1st period as following list below: 1) Field research was performed by conference meetings and problem-learning process, which participants participated in each step. There were two example groups: (1) Patients and families cooperated 2 times and (2) Nursing care cooperated 4 times in October-December 2013 (3) Combining the conclusions to set the key performance index and develop the index system in January-February 2014 (4) Recording the system in March-June 2014. Content analysis and percentage were used in this study. RESULTS: Nine organizations were engaged in this study; eight key performance indexes were established and the research recorded continuously for 4 months. There were three key performance indexes, which performed successfully: 1) Patients/caregivers received follow-up treatment continuously, 92.06%, 2) Patients/caregivers reported 89.69% satisfaction after asking the information, 3) Patients/families reported overall satisfaction of 92.11%. CONCLUSION: It is shown that recording the key performance index for the 1st period covered every quality of care. The Tawanchai Center and Out-patient Surgical Room under Srinagarind Hospital applied eight key performance indexes and found that three key performance indexes were feasibly implemented. For the 2nd period, the 1st outcome of key performance indices will be analyzed and developed including improving the software in order to record data and analyze the percentages automatically.

Development and Monitoring the Key Performance Indicators of the Quality of Care for Patients with Cleft Lips/Palates at Srinagarind Hospital.

BACKGROUND: Congenital deformities, such as cleft lips and/or cleft palates (CLP), have high incidences in the Northeast of Thailand. These birth defects can affect patient's quality of life. CLP patients need crucial and long-term treatments by a multidisciplinary team starting from prenatal stage to late adulthood. Patients and their families should involve in their own care, and their care objectives should correspond with healthcare providers. Besides the clinical outcome of interdisciplinary team, key performance indicators (KPIs) need to be developed in the hospital service unit in order to improve quality of care and treatment outcomes. OBJECTIVE: 1) to establish KPIs in hospital service units, and 2) to develop the information system to collect, analysis and improve the quality of CLP care. MATERIAL AND METHOD: A nurse coordinator was appointed in the Tawanchai Center to coordinate care. The three periods were conducted for the nurse coordinator to work with nine service units in Srinagarind Hospital for consensus on both qualitative and quantitative data to be used as service unit quality measurement. RESULTS: Thirty one KPIs from nine service units were established, collected and analyzed during a four-month period in 2014. The 20 KPIs achieved the unit targets. Two PKIs of the rates of complication with anesthesia during/after surgery in the first 24 hours and the rates of patient/caregiver's satisfaction in acquiring information from the officer were improving. There were 11 KPIs that did not achieve the targets. The coordinator nurse of the Tawanchai Center discussed with the service unit for the cause and how to improve the outcome. CONCLUSION: The monitoring KPIs will lead to improvement of outcome for better patient quality as well as benchmarking with other hospitals of Cleft Center. The KPIs from hospital service units with the monitoring and analysis of information by the nurse coordinator will enhance and lead to improvement of the quality of the patients and family centered care process.

Treatment of 4-5 year old patients with cleft lip and cleft palate in Tawanchai Center: prevalence and type of associated malformations.

BACKGROUND: Patients with cleft lip/palate may have other associated malformations but the reported prevalence and type of associated malformations varied between different studies. OBJECTIVE: To report the prevalence and the type of associated malformations in Northeastern Thai patients with cleft lip/palate. MATERIAL AND METHOD: A retrospective study of 123 cleft lip/palate patients aged 4-5 years was carried out at the Tawanchai Cleft Center, Khon Kaen University during the periodfrom October to December 2011. Data were collected by reviewing the patients medical records. RESULTS: Seventeen (14%) of the 123patients had associated malformations. Four (21%) of the 19patients with cleft palate, eleven (15%) of the 74 patients with clefts lip and palate, and two (7%) of the 30 patients with cleft lip had associated malformations. The organ systems affected by associated malformations were cardiovascular system (41%), craniofacial anomaly (23%), skeletal system (12%), urogenital system (12%) and central nervous systemn (12%). Atrial septal defect and tetralogy ofFallot were most common associated cardiovascular malformation found. CONCLUSION: The high prevalence of associated malformationsfound in patients with cleft lip/palate emphasizes the needfor a thorough screening of associated malformations and congenital heart disease ofall cleft lip/palatepatients.

Comparison of wound dehiscence and parent's satisfaction between spoon/syringe feeding and breast/bottle feeding in patients with cleft lip repair.

BACKGROUND: Cleft lip and cleft palate are the most common craniofacial anomalies affecting approximately 2.49 of every 1,000 children born in North-east of Thailand. Srinagarind Hospital has 100-150 cases of cleft lip each year. Children with cleft lip and palate need surgical procedures as soon as possible. After lip repair the normal recommendation is not using bottle or breast feeding for 2 weeks to avoid tension at the sutured area during sucking and possible cause of wound dehiscence. So this is quite complicated for the parents, and patients feel frustrated, cry, and move their head around, because of hunger which cannot easily be satisfied. Previous research found that sucking does not cause wound dehiscence, but mentioned no detail about severity of cleft. OBJECTIVE: Primary objective is to compare surgical wound dehiscence between breast feeding/bottle and spoon/syringe feeding after lip repair. MATERIAL AND METHOD: This is an experimental study: non-inferiority trials study. The population is the patients with cleft lip who underwent lip repair in Inpatient Department 3C, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University. The study period is during May 2010-February 2013. The total sample size in the present study is 192 participants, 96 cases breast/bottle feeding, 96 cases spoon/syringe feeding. The wound dehiscence rate was analyzed by Z-test. Parents'satisfaction is a qualitative data and was analyzed through content analysis. RESULTS: No statistical significant diference between breast/bottle and spoon/syringe groups (p-value = 0.320, 95% confidence interval -0.031-0.010). Parents were more satisfied to feed children by breast/bottle and patients were more relaxed with breast/bottle feeding. CONCLUSION: Breast/bottle feeding and syringe/spoon feeding have the same result on the surgical wound. Breast/bottle feeding are not causes of wound dehiscence.

Knowledge and satisfaction of caregivers of patients with cleft lip-palate at the Tawanchai Cleft Center.

The Northeast region has the highest rate of cleft lip-palate (CLP) deformities in Thailand. This born handicapped condition leads to complicated problems in many ways. The best treatment is managing the system to have good coordination by an interdisciplinary team that rehabilitate patients' physical and mental conditions so they can recover as well as possible. This study aimed to determine the (1) knowledge of taking care of patients and (2) service satisfaction of caregivers resulting from the development of Tawanchai Cleft Center's nursing care system as a 1-stop coordinating service in 2010. The study included 106 caregivers. We used a questionnaire to assess the knowledge level and the service satisfaction. Most of the patients had left unilateral complete cleft lip and palate (41%). The mother was the caregiver most of them time (68%); 43% had completed primary education, and 40% worked in agriculture. The average knowledge level among caregivers for the specialized care of patients with CLP was a good level ((Equation is included in full-text article.)= 3.71, SD = 0.81). The average knowledge level concerning the cause, the treatment guideline, and treatment by a multidisciplinary team of patients with CLP was a moderate level ((Equation is included in full-text article.)= 3.28, SD = 0.85). The satisfaction of caregivers regarding service at the In- and Out-patient Surgery Department was very good for all items ((Equation is included in full-text article.)= 3.54, SD = 0.54). The one-stop coordination service developed for caregivers neatly fit the needs of CLP patients and resulted in a moderate to good level of knowledge and a very good level of satisfaction regarding the specialized care needed.

Nursing care system development for patients with cleft lip-palate and craniofacial deformities at Srinagarind Hospital.

BACKGROUND: A holistic nursing care system for patients with cleft lip-palate (CLP) and/or craniofacial deformities was arranged by the Nursing Department, Srinagarind Hospital, which provides tertiary nursing care. The nursing care system was developed as per system theory via participating management with action research following the Deming Cycle (PDCA) divided into 3 phases. Participants included 117 nurses from 8 divisions caring for patients with CLP and 128 parent caregivers. The research instruments included: 1) situation analysis, 2) meeting and planning and 3) self-administered questionnaire. Groups were divided according to the age, physical and mental aspects of the patients. RESULTS: 1) The nursing care system under study comprised psychosocial care, breastfeeding, counseling, providing assistance in various ways in order to respond to problems of patients/families by the multidisciplinary team. There was also follow-up to evaluate the results and in order to give patients/families longitudinal and continuing care. 2) Minor research of 4 nursing sections was initiated. 3) Nursing care standards, manuals, regulations and innovations for the organization of eight nursing sections were created and implemented. CONCLUSION: The present study on developing a nursing care system for patients with CLP helped the team to (a) understand the overall nursing care system (b) to develop the organization of nurses by conducting research and (c) to create 12 works for developing care. The latter aimed to establish or create standards, nursing manuals, caring manuals, regulations, innovations, CDs, portfolios and informative cartoons to be applied systematically and shared across and between communities. The model for nursing care for patients with CLP in tertiary hospitals was clearly demonstrated.

The development of the nursing care system for patients with cleft lip-palate and craniofacial deformities at Tawanchai Cleft Center, Srinagarind Hospital, Khon Kaen, Thailand.

BACKGROUND: The highest incidence of cleft lip-palate and craniofacial deformities in Thailand occur in the Northeastern Region. There is the necessity for an interdisciplinary care team as well as the specialized care center with systematic coordinated care, thus "Tawanchai Cleft Center" is becoming a superior medical center for patients with cleft lip-palate and craniofacial deformities. Therefore, the development of the nursing care system for patients with cleft lip-palate and craniofacial deformities at Tawanchai Cleft Center, Srinagarind Hospital is extremely important and necessary. OBJECTIVE: To develop the nursing care system appropriate for a super tertiary hospital (Tawanchai Cleft Center). MATERIAL AND METHOD: It is a participation study which has 3 steps as follows, 1) Analyzing the situations and collecting the opinions of the 22 Out-patient Surgery Department staff and Tawanchai Cleft Center staff by using 6 questions, 2) Summarizing of the situation analysis from the meetings and the questionnaires, then using such summary as the guidelines for developing the nursing care system from January 2011 onwards, 3) evaluating the satisfaction after the 4 month development period (May-August 2011) with 106 caregivers by using 8 questions and being analyzed by the average value, percentage and standard deviation. RESULTS: 1) The nursing care system consisted of psychosocial care, breast feeding, counseling and other assistance as required. This various assistance responded to the patient/family problems by following the treatment guideline of the multidisciplinary team which uses the continuous evaluation processes for the holistic patient/family care. 2) The patients with complete cleft lip-palate were the most common type, found in 44 cases or 41.53 percent. The highest number of caregivers were mothers which were 68 percent; the average age of those mothers was 36 years old. The highest number of them finished elementary school at 43 percent and 40 percent were farmers. The satisfaction for the services of Tawanchai Cleft Center showed the average for each satisfaction subject all at very good level (x = 3.56, SD = 0.13). CONCLUSION: The care for patients with CLP and craniofacial deformities at Tawanchai Cleft Center Srinagarind Hospital has been developed in order to have the appropriate nursing care system to provide superior quality care, which provides patient-holistic care, as well as improving effective accessibility to the services. Thus, the patients/caregivers who are satisfied with given services, get continuing monitoring and treatment and are able to live their lives in the society happily.

Nursing outcome in patients with cleft lip and palate who underwent operation: follow-up cases.

BACKGROUND: Cleft lip and cleft palate are the most common craniofacial anomalies affecting approximately 2.5 of every 1,000 children born in North East of Thailand. Srinagarind Hospital has 150-200 cases of cleft lip and palate each year. The lengthy treatment process of care, requires continuity of care involving a multidisciplinary team. The holistic and interdisciplinary care is very important to patients, family, health care professionals and the health care system. After operation patients stay in hospital about 2-3 days, during this time they will receive information regarding how to take care of the wound,feeding and details about activities to avoid. Before patients leave hospital the nurse will confirm if parents can take care of patients wound, feeding, know about avoiding activities. The Nurses or health care professional can check patients progress again when they come back to hospital for follow-up. OBJECTIVE: To promote continuity care and resolve any problems for developing quality of care. MATERIAL AND METHOD: The present study is retrospective descriptive study. Data was collected from follow-up case forms using 205 medical records of patients with cleft lip and palate who were admitted in 3c ward Srinagarind Hospital between June 2010 to May 2011. The records were purposively selected for the study and recorded with a data collection form. RESULTS: 95.12% of patients with cleft lip and palate came back for follow-up. 2.44% of patients had wound infection. 7.69% of patients have flap separation. The authors also found that some care givers could not take care of the patients correctly and were not concerned about follow-up. CONCLUSION: To contracts the patients and family when they visit hospital for follow-up can make health care professional ensure the patients understand what they need to know and do, also can find any uncomfortable points/problem of patients/ family then can develop the strategies or system to solve the problem.

The treatment of 4-5 year-old patients with cleft lip and cleft palate in Tawanchai Center: follow-up.

BACKGROUND: The highest incidence of cleft lip and cleft palate in Thailand occurs in the Northeast Region. Tawanchai Center was set up 10 years ago to be a specialized medical care center where an interdisciplinary team provides care for cleft lip and cleft palate patients. There has never previously been a study about 4-5 year old patients treated and followed-up by the multidisciplinary team. OBJECTIVE: To study the 4-5 year old patient's with cleft lip and cleft palate who received treatment and follow-up in Tawanchai Center, Srinagarind Hospital. MATERIAL AND METHOD: This retrospective study was conducted using data from every 4-5 years old cleft lip and cleft palate patients' medical record of the patients who had the continuous multidisciplinary treatment care at Tawanchai Center, Srinagarind Hospital, Faculty of Medicine and Faculty of Dentistry, Khon Kaen University. The 123 case samples were collected during the 3 months of April-June 2012. The research instrument was a form for general data record and follow-up data record and then the data were analyzed by statistic and percentage. RESULTS: From the 123 cases of the 4-5 years old patients with cleft lip and cleft palate who received treatment at Tawanchai Center Srinagarind Hospital, it was found that 120 cases or 97.56 percent had an operation, 20 cases (16.26 percent) were found where patients came from Khon Kaen Province, 10 cases of each male and female. For this treatment, the majority (108 cases) used government insurance cards. The patients with cleft lip and cleft palate were most common and found to be 74 cases consisted of 44 male and 30 female. The diagnosis and follow-up of cleft lip and cleft palate patients were classified into 18 age ranges, with a total of 2,269 follow-up visits. The most common follow-up was for the 2-3 year old patients, which consisted of 410 times or 18.07 percent which consisted of 220 male and 190 female. Regarding the age range of the patients for the first diagnosis, the highest amount was 38 cases or 30.89 percent of 0-1 month newborn which were 22 males and 16 females. Regarding examination rooms used, the highest number of patients attended the out-patient surgical examination room (969 times, 30.66 percent), of which 526 times were male and 443 times female. The second highest number of patients attended the ENT room, 706 times or 22.33 percent of which 411 times were male and 295 female. The 2 patients with the highest number of follow-up were 87 and 65 times respectively. CONCLUSION: 123 cases of the 4-5 years patients had been continuously treated by the multidisciplinary team at Tawanchai Center Srinagarind Hospital. The highest number of visits was 87 or more than once per month, so it was a good opportunity for such a team to improve the efficiency and for developing the follow-up system and the diagnosis process for a baby with cleft lip and cleft palate before birth by use of ultrasound checking during pregnancy. Such a development was helpful for providing counseling towards mothers and families' preparation in order to give the most suitable age related treatment and full co-operative support to the children with cleft lip-cleft palate and family.

Quality of life in patients with cleft lip and palate after operation.

BACKGROUND: Cleft lip and cleft palate are the most common craniofacial anomalies. Srinagarind Hospital has 150-200 cases each year. The operating process of care, requires continuity of care involving a multidisciplinary team. When the patients go to hospital for an operation they experience pain, limited activity and also food is very different from normal life. When attending school they suffer speech articulation problems and feel shy and isolated, which has a detrimental affect on their life style and quality of life. OBJECTIVE: The main purpose of the study is to the present study quality of life in patients with cleft lip and palate after operation. MATERIAL AND METHOD: The present study is descriptive research using qualitative and quantitative approaches. The studied population were patients age 8-18 years old who were admitted at 3C Ward and Outpatient Department, Srinagarind Hospital. 33 patients were interviewed for the quantitative approach. Guideline for in-depth interview with 15 patients were used for the qualitative approach. Quantitative data were analyzed and presented in frequency, percentage and standard deviation. The qualitative data were analyzed through content analysis. RESULTS: Patients consider their QOL is high level, but in detail they still worry about self concept psychological well-being. From indept interview patients would like to get further treatment to minimize their scar as soon as possible. CONCLUSION: Patients consider their quality of life as high level, but they would like to get further treatment.