Keeping patients safe through medication review and management in the community.

BACKGROUND: There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home. AIMS: To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore. METHOD: This is a retrospective review of a 'good catch' reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed. FINDINGS: A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors. CONCLUSION: This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods.

Chronic wounds in a multiethnic Asian population: a cost of illness study.

OBJECTIVE: To estimate the 'cost of illness' arising from chronic wounds in Singapore. DESIGN: Incidence-based cost of illness study using evidence from a range of sources. SETTING: Singapore health services. PARTICIPANTS: We consider 3.49 million Singapore citizens and permanent residents. There are 16 752 new individuals with a chronic wound in 2017, with 598 venous ulcers, 2206 arterial insufficiency ulcers, 6680 diabetic ulcers and 7268 pressure injuries.Primary outcome measures expressed in monetary terms are the value of all hospital bed days lost for the population; monetary value of quality-adjusted life years (QALYs) lost in the population; costs of all outpatient visits; and costs of all poly clinic, use of Community Health Assist Scheme (CHAS) and emergency departments (EDs) visits. Intermediate outcomes that inform the primary outcomes are also estimated. RESULTS: Total annual cost of illness was $350 million (range $72-$1779 million). With 168 503 acute bed days taken up annually (range 141 966-196 032) that incurred costs of $139 million (range 117-161 million). Total costs to health services were $184 million (range $120-$1179 million). Total annual costs of lost health outcomes were 2077 QALYs (range -2657 to 29 029) valued at $166 million (range -212 to 2399 million). CONCLUSIONS: The costs of chronic wounds are large to Singapore. Costs can be reduced by making positive investments for comprehensive wound prevention and treatment programmes.

Retrospective matched cohort study of incidence rates and excess length of hospital stay owing to pressure injuries in an Asian setting.

Background: Little is known about stage 1 and 2 pressure injuries that are health care-acquired. We report incidence rates of health care-acquired stage 1 and stage 2 pressure injuries, and, estimate the excess length of stay using four competing analytic methods. We discuss the merits of the different approaches. Methods: We calculated monthly incidence rates for stage 1 and 2 health care-acquired pressure injuries occurring in a large Singapore acute care hospital. To estimate excess stay, we conducted unadjusted comparisons with a control cohort, performed linear regression and then generalized linear regression with a gamma distribution. Finally, we fitted a simple state-based model. The design for the cost attribution work was a retrospective matched cohort study. Results: Incidence rates in 2016 were 0.553% (95% confidence interval [CI] 0.55, 0.557) and 0.469% (95% CI 0.466, 0.472) in 2017. For data censored at 60 days' maximum stay, the unadjusted comparisons showed the highest excess stay at 17.68 (16.43-18.93) days and multi-state models showed the lowest at 1.22 (0.19, 2.23) days. Conclusions: Poor-quality methods for attribution of excess length of stay to pressure injury generate inflated estimates that could mislead decision makers. The findings from the multi-state model, which is an appropriate method, are plausible and illustrate the likely bed-days saved from lowering the risk of these events. Stage 1 and 2 pressure injuries are common and increase costs by prolonging the length of stay. There will be economic value investing in prevention. Using biased estimates of excess length of stay will overstate the potential value of prevention.

Healing outcomes and predictors among patients with venous leg ulcers treated with compression therapy.

OBJECTIVE: This study aimed to compare the healing outcomes between three types of compression therapy-two-layer bandage (2LB), four-layer bandage (4LB), and compression stockings, and to identify the predictors of venous leg ulcer (VLU) healing. METHOD: A retrospective review of the medical records of patients diagnosed with VLU between 2011 and 2016 in Singapore was conducted. Univariate and multivariate analyses were done between healed and unhealed VLU patients at three and six months, based on potential factors, ranging from demographic profile to comorbidities and treatment-related variables. RESULTS: Data from 377 patients' medical records were analysed. The healing rates with the three types of compression system, 4LB, 2LB and compression stockings, were 22.3%, 34.9% and 8.7% respectively at three months; at six months they were 44.2%, 41.9% and 34.8% respectively. Patients on 2LB reported a significantly higher proportion of healed ulcers at three months (p=0.003) but at six months there was no difference in healing rates between the three types of therapy. At three and six months, the duration of compression therapy was found to be an independent predictor of healing (p<0.001). CONCLUSION: In this study, the 2LB appeared to show the most favourable healing outcome in the short-term but as VLUs persisted beyond the months, the type of compression system used did not make a difference in the healing outcome. Our findings suggested that, as the duration became more prolonged, VLUs became more resistant to healing despite compression therapy. Therefore, it may be necessary for clinicians to consider adjuvant therapies for hard-to-heal ulcers at an earlier stage.

Development and validation of the incontinence associated dermatitis knowledge, attitude and practice questionnaire.

AIM: This study aimed to develop and test the validity and reliability of the Knowledge, Attitudes and Practices of Incontinence-associated Dermatitis Questionnaire (KAP-IAD-Q) for Nurses. METHODS: A psychometric validation design was employed. Phase I of the study entailed the development of items through an extensive literature review and a double Delphi procedure with 11 experts specialised in wound, ostomy and continence to examine content validity of the KAP-IAD-Q. Phase II involved administering the KAP-IAD-Q to a convenience sample of 263 Registered Nurses from a public hospital in Singapore to evaluate its construct validity, internal consistency and test-retest reliability. RESULTS: The instrument showed acceptable content validity (S-CVI = 0.85). Exploratory factor analysis showed all 22 items demonstrated strong factor loadings >0.4 and the four factors KAP-IAD-Q explained 58.1% of total variance. The four factors were☹1) knowledge om IAD aetiology and identification, (2) knowledge on IAD risk factors; (3) attitudes, and (4) practices. The overall internal consistency was excellent (Cronbach's α = 0.913). The KAP-IAD-Q showed good overall test-retest reliability as well (ICC = 0.89 (95% CI 0.69-0.96, p < 0.001). CONCLUSION: The KAP-IAD-Q demonstrated good psychometric properties and is effective in measuring levels of IAD-related KAP among nurses. Further confirmation of the proposed factor structure is recommended. Future research should explore determinants of nurses' KAP and associations between IAD knowledge, attitudes and practices.

Pressure injuries among admissions to a hospital in the tropics.

We report incidence rates for pressure injuries seen in an acute hospital in Singapore that were classified as Stage 3 or Stage 4. The characteristics of patients and the factors that explain variation in the primary outcome of duration of hospital stay are summarized. Existing data were available from Singapore General Hospital for all admissions from January 2016 to December 2019. Univariable analysis was done and a multivariable Poisson regression model estimated. Incidence rates declined from 4.05 to 3.4 per 1000 admissions in the 48 months between 2016 and 2019. The vast majority were community acquired with 75% in admission from the patients' home. Factors that explain variation in length of stay were, ethnicity; site of injury; community versus healthcare associated; inter-hospital transfer; fracture as reason for admission; and the number of days between admission and assessment of wound by specialist nurse. Stage 3 and 4 injuries arise in a home environment most often and are subsequently managed in acute hospital at high cost. These are novel epidemiological data from a hospital in the tropics where the potential to improve outcomes, implement screening and prevention, and thus increase the performance of health services is strong.

Preparation and response to COVID-19 outbreak in Singapore: A case report.

The COVID-19 pandemic has an overwhelming impact on the nursing profession. Nurses play a vital role before and during pandemics, with nurse leaders taking the lead in preparation for outbreaks. In response to an outbreak, early recognition and preparation for the increasing threat, managing staffing challenges together with the well-being of nurses are of utmost importance. Strategies to promote physical distancing while not compromising continuing nursing education and patient care are also essential. With prompt actions and coordinated efforts, risk of spreading the virus within the healthcare sector can be kept at the minimum. As nurses are in the frontline of healthcare, their confidence in being well-supported by the hospital should be maintained. This case report describes the preparation and response of the nurses in Singapore General Hospital to the COVID-19 outbreak in Singapore.