Official Journal of Malaysian Public Health Physicians ... 11... · Official Journal of Malaysian Public Health Physicians’Association Deputy Chief Editor Volume 11(Suppl 5) 2011

Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011 The 6th

National QA Convention 18th

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October 2011

Official Journal of Malaysian Public Health Physicians’Association

Volume 11(Suppl 5) 2011

MJPHM

EDITORIAL BOARD

Chief Editor

Prof. Dato’ Dr. Syed Mohamed Aljunid

(United Nations University – International Institute for Global Health)

Deputy Chief Editor

Assoc. Prof. Dr. Sharifa Ezat Wan Puteh

(Universiti Kebangsaan Malaysia)

Members:

Assoc. Prof. Sharifah Zainiyah Syed Yahya University Putra Malaysia

Dr. Lokman Hakim Sulaiman Ministry of Health Malaysia

Assoc. Prof. Dr Retneswari Masilamani University Malaya

Assoc Prof. Dr. Mohamed Rusli Abdullah University Sains Malaysia

Assc. Prof. Dr Saperi Sulong University Kebangsaan Malaysia

Assc. Prof. Dr Maznah Dahlui University Malaya

Dr. Roslan Johari Ministry of Health Malaysia

Dr. Othman Warijo

Dr. Norfazilah Ahmad

Ministry of Health Malaysia

University Kebangsaan Malaysia

Dr. Amrizal Muhd Nur United Nations University–International

Institute for Global Health (UNU-IIGH)

Chief Editor Malaysian Journal of Public Health Medicine (MJPHM)

United Nations University - International Institute for Global Health (UNU-IIGH)

Universiti Kebangsaan Malaysia Medical Centre (UKMMC)

Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur

Malaysia

ISSN: 1675–0306

The Malaysian Journal of Public Health Medicine is published twice a year

Copyright reserved @ 2001

Malaysian Public Health Physicians’ Association

Secretariate Address:

The Secretariate

United Nations University - International Institute for Global Health (UNU-IIGH)

Universiti Kebangsaan Malaysia Medical Centre (UKMMC)

Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur

Malaysia

Tel: 03-91715394 Faks: 03-91715402 Email: [email protected]

mailto:[email protected]



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Official Journal of Malaysian Public Health Physicians’Association

Volume 11(Suppl 5) 2011

MJPHM

6th

NATIONAL QUALITY ASSURANCE CONVENTION 2011

18-21 OCT 2011

DEWAN WAWASAN 2020, KANGAR, PERLIS

EDITORIAL BOARD

Chairman: Ms Haniza Mohd Anuar

Secretary: Ms Samsiah Awang

Members: Dr Nur Ezdiani Mohamed

Datin Dr Siti Haniza Mahmud

Dr Roslinah Ali

Mr Ramli Zainal

Ms Look Chai Hong

In Cooperation with

Perlis State Health Department

Organised by

Ministry of Health

Persatuan Pakar Perubatan Kesihatan Awam Malaysia



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CONTENTS

ORAL PRESENTATION

OP-01 OPEN ACCESS ENDOSCOPY SERVICE REDUCES WAITING TIME AND INCREASES GASTROINTESTINAL CANCER DETECTION Mahadevan D, Dharmendran R, Azrina A, Vijaya S, Kandasami P, Ramesh G, Jasiah Z.

1

OP-02 MENINGKATKAN TAHAP PENGLIHATAN PESAKIT AMBLIOPIA DI KLINIK OFTALMOLOGI Farawahida Kasmira F, Nur Liyana I, Nurul Ain MZ, Abdul Mutalib O, Mazliana A, Maizun MZ, Laila A.

2

OP-03 MENINGKATKAN KOMPETENSI PELATIH PROGRAM DIPLOMA PEMBANTU PERUBATAN MELALUI INTERVENSI SIMULASI KLINIKAL Elengovan V, Nazri A, Yong KK, Zafri Y, Liew CF.

3

OP-04 MENINGKATKAN KEHADIRAN IBU MENGANDUNG KE KLINIK PERGIGIAN Nor Sarah A, Suhaila AK, Nur Arliza P, Wan Mohd Ridzuan WJ.

4

OP-05 REDUCING E-PRESCRIPTION ERROR IN A HOSPITAL INPATIENT PHARMACY Wan Najbah NN, Ngan YS, Muhd Nor Hazli N, Ng KY, Ching MW, Tan HF.

5

OP-06 RE-ENGINEERING THE PROCESS OF OBTAINING SPECIAL FORMULARY DRUGS BY ONCOLOGY PATIENTS Tan PL, Azhari Wasi NA, Dhillon HK, Buang A, Sulaiman CZ, Mohd Zakaria IE, Tan WC, Poopaladurai D.

6

OP-07 MENURUNKAN KEJADIAN ANEMIA DI KALANGAN IBU HAMIL PADA USIA KANDUNGAN 36 MINGGU Norasikin M, Zaitun I, Roslenda M, Mazliza M, Rubiah L, Masriah M.

7

OP-08 IMPROVING ADHERENCE TO BLOOD SAMPLING TIME FOR THERAPEUTIC DRUG MONITORING IN A GOVERNMENT HOSPITAL Rosdi MZ, Dang CC, Ku SC, Norshazareen AM, Lim CW, Tan BL.

8

OP-09 THE BRAINWAVES SYSTEM: DEVELOPMENT OF A MIND STIMULATING SYSTEM TO IMPROVE NEUROCOGNITIVE HEALTH BY INCREASING ALERTNESS IN THE WORKPLACE Zalina I, Wan Asim WA, Idris L, Aida Fadriah M, Wan Raihana WA, Yang SA, Kumar J, AlHindi R, Gisely V.

9



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OP-10 MENINGKATKAN PERATUSAN KEPATUHAN TERHADAP PERAWATAN PESAKIT DENGAN INFUSI INTRAVENA DI WAD OBSTETRIK & GYNAECOLOGY Nancy B, Sania L, Diviki T, Anita M, Zabidah J, Rusti T, Jockina M.

10

OP-11 IMPROVING TIME INTERVAL FROM DECISION TO CAESAREAN DELIVERY FOR FETAL DISTRESS CASES Yuzainov A, Nurul Khairiyah K, Norul Akhma AH, Rahmah N, Norraihan H, Suriwati I.

11

OP-12 INCREASING LOWER SEGMENT CAESARIAN SECTION WITHOUT POST PARTUM HAEMORRHAGE Nor Jumizah AK, Lim KY, Faridah MY, Wan Mazlina WR, Maziati M, Suhainiza S, Norleeza MN.

12

OP-13 IMPROVING THE PERCENTAGE OF ASTHMATICS RECEIVING OPTIMAL ASSESSMENT DURING FOLLOW UP IN HEALTH CLINICS Nor Azila MI, Shuaita MN, Uthayalaxmi N, Ahmad Nazifi S, Toh LS,

Mohd Azrul Z, Nor Izzah AS.

13

OP-14 MENINGKATKAN PENGURUSAN YANG EFEKTIF BAGI IBU HAMIL DENGAN ANEMIA DI KLINIK KESIHATAN Suzaini MD, Junaidah I, Norhayati S, Nur Hazwani R, Rosnani R.

14

OP-15 MENGURANGKAN KEKERAPAN PESANAN LUAR JANGKA DARI UNIT PEMESAN BAGI ITEM BUKAN UBAT DI UNIT PEROLEHAN DAN PEMBEKALAN Noor Mariati O, Siti Masyitah MT, Noorulhuda S, Lee LG, Azizah M, Khairul Anuar M, Norsiah MN.

15

OP-16 ROLE OF THE PHARMACIST IN IMPROVING TARGETED INTERNATIONAL NORMALISED RATIO VALUE OF PATIENTS ON WARFARIN THERAPY Shakirin SR, Izrul Azwa ML, Tan SY, Cheah SY, Wong MK, Chiew CW.

16

OP-17 REDUCING THE INCIDENCE OF VENTILATOR ASSOCIATED PNEUMONIA AMONG ICU PATIENTS Rozaidah AK, Norlida AB, Fatimah A, Nor Azuwa J, Che Zakiah O, Dominica Rose JS Daniel.

17

OP-18 MENINGKATKAN PERATUS BRONKIAL ASMA TERKAWAL Jayashree M, Shahrul Bariyah A, Norsiah MN, Ruzita S.

18

OP-19 REDUCING INCIDENCE OF SEVERE NEONATAL JAUNDICE Gadung A, Christina BL, Adeline WSF, Juliana H, Hilda B, Iya R.

19



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OP-20 ACHIEVING INTERNATIONAL NORMALISED RATIO TARGETS AND SATISFACTION OF WARFARINISED PATIENTS Subramaniam T, Fudziah A, Jeyaindran S, Suliyana Y, Lim SC, Chong MF, Cheng PL, Teng SC.

20

POSTER PRESENTATION

PP-01 REDUCING THE PERCENTAGE OF CLINICAL PROGRESSION OF SEVERE NON- PROLIFERATIVE DIABETIC RETINOPATHY CASES TO PROLIFERATIVE DIABETIC RETINOPATHY STAGE OVER 1 YEAR IN AN OPHTHALMOLOGY DEPARTMENT Adeline ML Khaw, Chariya Eh Chot, SL Ng, A Rosli

21

PP-02 MENGURANGKAN PENCEMARAN LONGKANG DAN SALIRAN AWAM OLEH SISA MINYAK TERPAKAI Azraei R, Ganggaraj A, Abdul Hamid MD.

22

PP-03 REDUCING THE NUMBER OF MEDICATION ADMINISTRATION ERRORS IN A GENERAL PAEDIATRIC WARD Hiew CY, Lee ML.

23

PP-04 IMPROVING PROPER USAGE OF FETAL MOVEMENT CHART AMONG PREGNANT WOMEN M Nazari J, Maskinah A, Haizuna MY, Saruah B, Aishah B, Ismail A, Adinegara.

24

PP-05 REDUCING FREQUENCY OF READMISSION OF PATIENTS WITH SCHIZOPHRENIA AFTER LAST DISCHARGE Ruzita J, Dandaithapani T, Muslim AR, Rasidi D, Rozali I, Basiah A, Afidayati A.

25

PP-06 MENINGKATKAN AKTIVITI PENYUSUAN DI KALANGAN JURURAWAT DI TEMPAT KERJA Norbaizora M, Ruzita MY, Sapinah MK, Kalsom M, Rohani H, W Mohd Faizal A, Ahmad Syahir S, Norhasriza Z, Nor Syarahani J.

26

PP-07 INCREASING THE SUCCESS RATE OF QUIT SMOKING CLINIC AMONG ADOLESCENTS Arbaiah O, Marina MS, Zaleha J, Zainal AR, Hariyaton R.

27

PP-08 MENINGKATKAN PENGESANAN KOMPLIKASI PESAKIT DIABETES YANG LENGKAP DI KLINIK KESIHATAN Norhana Y, Fatimah M, Mazlinah M, Kamilah M, Che Azizah A.

28

PP-09 REDUCING REJECTION RATE OF BLOOD FILM MALARIA PARASITE SAMPLE DUE TO UNSATISFACTORY SMEAR FROM EMERGENCY AND

29



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TRAUMA DEPARTMENT Tchong FL, Nadiah AR, Noriah Y, Timothy B, Marilyn AA.

PP-10 IMPROVING THE PASSING RATE OF NURSING STUDENTS IN ANATOMY AND PHYSIOLOGY SUBJECTS Tan SC, Chin SK, Khaw ES, Rogayah I, Lim JK.

30

PP-11 MENGURANGKAN PERATUS ANAEMIA SEDERHANA DI KALANGAN IBU HAMIL PADA MINGGU 36 Norazlina MN, Aida Rahayu AG, Shaebah MJ, Asma I, Noor Azhan A.

31

PP-12 REDUCING CENTRAL VENOUS LINE RELATED BLOOD STREAM INFECTIONS AMONG PAEDIATRIC ONCOLOGY PATIENTS Yeoh SL, Tan PY, Suhaila R, Azimah A, Nor Hafiza R.

32

PP-13 OPTIMISATION OF PHARMCARE SERVICE IN A TERTIARY HOSPITAL Giam WL, Azhari Wasi NA, Buang A, Dhillon HK, Mohd Zakaria IE, Lee CE, Jinan Taib JT, Ismail NS, Syed Othman SR, Abdul Wahab AR.

33

PP-14 IMPROVING ADMISSION TIME AT A MATERNITY PATIENT ASSESSMENT CENTRE Mohd Azri MS, Lim GL, Puziah Y, Mohd Nasir O, Mohammad Faidzol T.

34

PP-15 MENGURANGKAN PERATUS X-RAY BERULANG YANG TINGGI DI KLINIK PERGIGIAN Morni AR, Siti FJ, Amran MY, Hasniza J, Irdawaty M.

35

PP-16 MENGURANGKAN KETIDAKSEIMBANGAN BADAN DI KALANGAN PESAKIT WARGA TUA DI WAD KRONIK Mike C, Fung Z, Tay LH, Nandi Dewi R, Mariani A.

36

PP-17 MINIMISING THE FILLING ERRORS IN A SPECIALIST CLINIC PHARMACY Siow CC, Menaga K, Noor Shafizah J, Muhd Redhuan N.

37

PP-18 RE-ENGINEERING THE CATARACT SURGERY WAIT-TIME STRATEGY Shubhashini Y, Poh EP, Gong VHM, Kogilavaani J, Kasturi R, Che Sam AK, Normadiniatul SMH, Nur Fazlina MN.

38

PP-19 MENURUNKAN PERATUSAN PENOLAKAN KES PEMBEDAHAN DEWAN BEDAH Nurul Atikah H, Mohd Zahidi H, Kartini M, Sahaimi M, Nik Abdul Aziz RS.

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PP-20 REDUCING THE INCIDENCE OF THIRD DEGREE TEAR IN OBSTETRICS & GYNAECOLOGY DEPARTMENT Molen A, Myat SY, Lily D, Chanic B., Landsee DM, Juliana DJ, Abby B.

40

PP-21 IMPROVING TURN-AROUND-TIME OF CULTURE & SENSITIVITY TESTING Wong MK, Abdullah A, Justin F.

41

PP-22 CLINICAL AND ECONOMIC IMPACT OF PHARMACIST-RUN MEDICATION THERAPY ADHERENCE CLINIC SERVICE ON PATIENTS WITH TYPE 2 DIABETES Navin Kumar L, Chin ST, Rachel T, Lim KY, Fudziah A.

42

PP-23 INCREASING RETENTION RATE OF FISSURE SEALANT AMONG PRIMARY SCHOOL CHILDREN Hajar HR, Vijayamanohar K, Wan Aini WY, Nadia DB, Umi A.

43

PP-24 INCREASING PERCENTAGE OF ASTHMA CONTROL MONITORING AT DISTRICT HEALTH CLINICS Mohd Fozi K, Junaidah I, Azirah Y, Nurul Azlyn MY, Mahani K, Ali O, Mardiana A, Hamiza H.

44

PP-25 IMPROVING DETECTION RATE OF DIABETIC FOOT AMONG PATIENTS WITH DIABETES Samurah AR, Ganespathy P, Ibrahim AF, Molina J.

45

PP-26 MENINGKATKAN PERATUS “PREMIS BERSIH” KANTIN SEKOLAH MENENGAH Norazema AA, Samsir Asuwat S, Mohd Zulfadhli MS, Mohd Zahari Y, Md Kamal Ariffin AG, Zainal Abidin I, Azmi A, Jamaliah J.

46

PP-27 MENURUNKAN KEJADIAN ANEMIA SEDERHANA DI KALANGAN IBU HAMIL M. Adam MA, Nini Shuhaida MH, Rohanita N, Badariah S, Badariah M,Wan Hafizah WM.

47

PP-28 DELAY IN INDUCTION OF LABOUR WITH OXYTOCIN Nik Azi Azuha NH, Norhayati A, Norizah M, Saluwani AH, Nuraini M.

48

PP-29 MENINGKATKAN PENGETAHUAN PESAKIT TENTANG PERUBAHAN RUPA UBAT DI FARMASI PESAKIT LUAR Norhasmani M, Abby Ang SY, Rashidah AR, Omar O, Norfajariah I, Arzarizah A.

49

PP-30 MENGURANGKAN KADAR KEJADIAN „LSCS WOUND BREAKDOWN’ Anna T, Masni L, Lena C, Chua YL, Jeanyfer L, Mohd FA, Lucina L.

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PP-31 MENINGKATKAN AKTIVITI FIZIKAL MELALUI KEMPEN 10,000 LANGKAH DI KALANGAN MASYARAKAT Norasikin M, Rubiah L, Masriah M, Zaitun I, Masliza M, Roslenda M.

51

PP-32 ADHERENCE PROGRAMME TO IMPROVE TREATMENT RESPONSE IN HIV TREATMENT-NAÏVE PATIENTS AT INFECTIOUS DISEASE CLINIC Chow TS, Low LL, Zuhaila MI, Cheang LF, Asma A, Zakiah K, Norlizawati S.

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Mahadevan D, Dharmendran R, Azrina A, Vijaya S, Kandasami P, Ramesh G, Jasiah Z. Department of Surgery, Tuanku Ja’afar Hospital, Seremban, Negeri Sembilan.

Selection of Opportunities for Improvement

In Malaysia, gastrointestinal cancer patients present late. There is no guideline to identify high risk patients. Thus appointments are given without urgency, leaving some patients with late appointments for specialist consultation. Failure to identify high risk patients in the health centre, followed by delay in diagnostic endoscope procedure, is the reason for the delay in diagnosis, thus narrowing the treatment options to palliation.

Key Measures for Improvement Time from presentation to health centre to endoscopic procedure is the direct indicator with the standard of two weeks and cancer detection rate due to introduction of Open Access Endoscopy (OAE) service compared to routine referral is the proxy indicator.

Process of Gathering Information

A three-pronged approach was undertaken. 1)Phase 1(2006): Development of the weighted scoring system using cancer database and multivariate logistic regression model, 2)Phase 2(2007-2008): Estimating positive predicting value, 3)Phase 3(2008-2010): Comparison of OAE to conventional referral system. This is a cross sectional study to determine diagnostic yield of both systems.

Analysis and Interpretation

From January 2004 till July 2006, a total of 59 stomach and 20 oesophageal cancers were studied, with more than 90% of these being advanced disease. Mean time taken in the conventional referral system, from the first appearance of cancer symptoms to the time of endoscopic procedure was 34 weeks. The delay in colonoscope appointment was 12-20 weeks.

Strategy for Change

We reduced the work process for referral and getting appointment for endoscope service by introducing OAE. Medical officers in health centres could order endoscope appointment for high risk patients directly without prior specialist consultation. OAE service in Negeri Sembilan is the first OPEN ACCESS programme in Malaysia.

Effect of Change

After the implementation of strategies, all referral via OAE were done within 2 weeks, more stomach cancers were diagnosed early and there was high yield of endoscope procedure. By identifying high risk patients and reducing the endoscope appointment time, the cancer detection could be increased and treatment hastened. Without this, high risk patients were not identified and consequently, their cancers diagnosed late.

The Next Step

Consolidate and publish the findings, implement OAE nationwide.

OP-01 Open Access Endoscopy Service Reduces Waiting Time and Increases Gastrointestinal Cancer Detection



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Farawahida Kasmira F, Nur Liyana I, Nurul Ain MZ, Abdul Mutalib O, Mazliana A, Maizun MZ, Laila A. Jabatan Oftalmologi, Hospital Kuala Krai, Kelantan.

Pemilihan Peluang untuk Penambahbaikan

Ambliopia boleh berlaku pada pelbagai peringkat umur dan jika tidak dirawat awal boleh menyebabkan kebutaan kekal. Peningkatan tahap penglihatan (VA) di kalangan pesakit Ambliopia yang komplians terhadap rawatan pengatupan boleh mencapai 77%. Seterusnya, meningkatkan komplians terhadap rawatan pengatupan akan meningkatkan VA pesakit Ambliopia.

Pengukuran Utama Penambahbaikan

Untuk menilai VA dan mengenalpasti faktor yang menyumbang kepada VA di kalangan pesakit Ambliopia yang menjalani rawatan dan seterusnya menjalankan tindakan penambahbaikan bagi meningkatkan VA kepada 77%. Komplians dinilai dengan memakai kaca mata beralat refraksi terkini, membuat rawatan pengatupan 2 jam sehari dan menghadiri temujanji.

Proses Pengumpulan Maklumat

Kajian bermula Jun 2009 hingga Mac 2011. Maklumat diperolehi dengan menggunakan borang soal selidik, buku temujanji pesakit dan kad rawatan pesakit. Kajian penilaian keberkesanan tindakan penambahbaikan dijalankan terhadap pesakit dan kakitangan klinik.

Analisa dan Interpretasi

Peningkatan VA ialah 12% manakala faktor penyumbang kepada VA pesakit Ambliopia ialah kurang pengetahuan tentang rawatan, waktu sekolah yang panjang (lebih 7 jam), tidak faham arahan pengatupan, tidak yakin kepada rawatan pengatupan, tidak memakai kaca mata dengan ralat refraksi terkini dan gagal menghadiri temujanji yang ditetapkan.

Strategi Penambahbaikan

Menyediakan Prosedur Operasi Terpiawai (SOP) pengendalian pesakit Ambliopia, menjalankan aktiviti pendidikan kesihatan dan meningkatkan kemudahan sistem temujanji.

Kesan Perubahan

Kajian menunjukkan VA pesakit Ambliopia telah meningkat kepada 78% dengan peningkatan komplians terhadap rawatan pengatupan.

Langkah Seterusnya

Memastikan pengendalian semua pesakit Ambliopia mengikut Prosedur Operasi Terpiawai (SOP) serta mempertingkatkan aktiviti pendidikan kesihatan dan program saringan penglihatan di peringkat tadika, sekolah rendah serta projek komuniti sebagai langkah pencegahan Ambliopia.

OP-02 Meningkatkan Tahap Penglihatan Pesakit Ambliopia di

Klinik Oftalmologi



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Elengovan V, Nazri A, Yong KK, Zafri Y, Liew CF. Bahagian Pengurusan Latihan, Kementerian Kesihatan Malaysia, Wilayah Persemutuan Putrajaya.


Hasrat Institusi Latihan Kementerian Kesihatan Malaysia adalah untuk melahirkan anggota kesihatan yang berilmu, kompeten dan pengamal selamat bagi merealisasikan dasar dan wawasan kesihatan Negara. Walaubagaimanapun, kemampuan dan kualiti graduan yang dihasilkan sering dipersoalkan. Isu kurang kompetens serta faktor seperti peluang pendedahan, suasana pembelajaran, penyeliaan, kerelaan pesakit, isu keselamatan pesakit dan perundangan membawa kepada theory-practice gap di unit klinikal.


Kajian ini bertumpu ke arah meningkatkan kompetensi pelatih ke paras piawai 85%. Model of Skills Acquisition (Dreyfus & Dreyfus, 1980) digunakan sebagai indikator bagi mengukur kombinasi kemahiran, pengetahuan, sikap, nilai dan keupayaan pada peringkat kompetens dalam pengendalian kes klinikal.


Kajian ini dijalankan dari 4 hingga 30 Julai 2010 dan melibatkan sampel seramai 50 orang pelatih dari Kolej Pembantu Perubatan Ulu Kinta, Alor Setar, Seremban dan Kuching. Ujian Objective Structured Clinical Examination (OSCE) berasaskan senario klinikal digunakan untuk mengukur komponen kompetensi sebelum dan selepas intervensi simulasi. Analisis dan Interpretasi Hasil kajian sebelum intervensi menunjukkan bahawa pelajar hanya mampu memperolehi min skor 51.19% dengan sisihan piawai 10.89. Prestasi ini tidak memenuhi piawai latihan. Strategi Penambahbaikan

Sebagai langkah penambahbaikan, Kolej Pembantu Perubatan telah memperkenalkan pendekatan „Intervensi Simulasi Klinikal dalam Meningkatkan Kompetensi Pelatih‟. Integrasi simulasi dalam pedagogi latihan menggunakan senario kes klinikal sebagai stimulus pembelajaran dan dibantu oleh pelakon, manikin, peralatan ICT serta pengajar sebagai fasilitator dalam pengendalian kes klinikal.

Kesan Penambahbaikan Kajian keberkesanan menunjukkan bahawa gabungan program simulasi dan penempatan klinikal (Study Group) dapat menganjakkan prestasi dan kompetensi pelatih dari paras 51.2 % ke paras 77.3 % (Pre-test- x: 51.19; sd: 10.89; Post-test- x: 77.30, sd: 6.90) berbanding dengan pelajar yang hanya mengikuti program penempatan klinikal di Hospital (Control Group Pre-test- x: 43.72; sd: 12.09; Post-test- x: 55.09, sd: 14.72). Walaupun piawai yang ditetapkan adalah 85.0%, intervensi ini telah memberi impak dan kejayaan dalam meningkatkan prestasi, kompetensi dan keyakinan pelatih. Langkah Seterusnya Aktiviti pengajaran dan pembelajaran yang menggunakan pendekatan simulasi klinikal dapat membangunkan kompetensi klinikal disamping memudahcarakan pemindahan ilmu kepada situasi klinikal sebenar. Impak dan kejayaan projek ini memberi ruang dan peluang bagi memperluaskan dan mengintegrasikan konsep simulasi klinikal dalam kurikulum serta membangunkan konsep makmal simulasi.

OP-03 Meningkatkan Kompetensi Pelatih Program Diploma Pembantu Perubatan melalui Intervensi Simulasi Klinikal



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Nor Sarah A, Suhaila AK, Nur Arliza P, Wan Mohd Ridzuan WJ. Klinik Pergigian Peringgit, Melaka.


Ibu mengandung, selain mengalami masalah karies, cenderung mendapat penyakit gusi (periodontium) kerana perubahan hormon semasa hamil. Jika dibiarkan, penyakit periodontium mendedahkan ibu mengandung kepada risiko mendapat kelahiran pramatang dan bayi dilahirkan kurang berat badan. Sejak tahun 2004 hingga 2009 didapati kehadiran ibu mengandung ke Klinik Pergigian Peringgit sekitar 30% sahaja.


Peratusan kehadiran baru ibu mengandung ke klinik pergigian berbanding kehadiran baru ibu mengandung ke KKIA adalah indikator District Specific Approach (DSA) yang ditetapkan dengan piawaian lebih dari 50%.


Kajian irisan lintang dijalankan pada Januari dan Februari 2010 bagi mengenalpasti faktor ibu mengandung kurang membuat pemeriksaan gigi. Dua set borang soal selidik melibatkan 40 orang ibu mengandung dan 22 orang anggota pergigian dan Klinik Kesihatan Ibu dan Anak (KKIA) digunakan.

Analisis dan Intepretasi

Majoriti ibu mengandung tahu mengenai penyakit pergigian (71.1%) dan pernah diberitahu agar membuat pemeriksaan gigi (68.4%). 57.9% menyatakan mereka telah membuat pemeriksaan gigi. Majoriti (73.7%) tidak pernah diberi ceramah mengenai kesihatan pergigian. 92.1% menyatakan tiada masalah untuk pergi membuat pemeriksaan di klinik gigi di tingkat atas. Majoriti dari anggota pergigian dan KKIA (68.2%) menyatakan bahawa maklumat kesihatan pergigian di KKIA tidak mencukupi.


Beberapa langkah penambahbaikan telah dilaksanakan termasuklah menempatkan Pegawai Pergigian di KKIA, mewujudkan borang pemeriksaan dan rujukan untuk rawatan pergigian yang akan dikepilkan ke dalam buku antenatal bagi tujuan peringatan serta mengelakkan dari keciciran ibu mengandung mendapatkan pemeriksaan pergigian. Selain itu, pamplet dan poster kesihatan pergigian diedarkan di KKIA sebagai bahan bacaan ibu mengandung dan ‟Fast lane‟ bagi ibu mengandung yang datang mendaftar di klinik pergigian.

Kesan Penambahbaikan

Peratusan kehadiran baru ibu mengandung meningkat kepada 60.5% (Jan-Dis 2010).

Langkah Seterusnya

Kerjasama berterusan antara pihak pergigian dan KKIA akan dipertingkatkan. Laporan kehadiran ibu mengandung ke klinik pergigian akan dihantar ke KKIA & Pegawai Perubatan Daerah (PPD) untuk makluman dan pemerhatian. Ibu mengandung yang tercicir akan dihubungi melalui telefon untuk temujanji pemeriksaan pergigian.

OP-04 Meningkatkan Kehadiran Ibu Mengandung ke Klinik Pergigian



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5

Wan Najbah NN, Ngan YS, Muhd Nor Hazli N, Ng KY, Ching MW, Tan HF. Pharmacy Department, Putrajaya Hospital, Wilayah Persekutuan Putrajaya.


The Computer-based Physician Order Entry (CPOE) system has been shown to reduce the number of prescription errors. However, it may also lead to new kinds of prescription errors. A study in 2009 in Putrajaya Hospital demonstrated that the percentage of prescription errors in in-patient pharmacy was 5.32%. This project aimed to reduce the percentage of prescription errors in in-patient pharmacy, Putrajaya Hospital (HPJ).

Key Measures for Improvement

The proposed standard for percentage of prescription errors in Putrajaya Hospital (HPJ) was 0%.


All in-patient prescriptions were sampled from 18 till 24 October 2010. During this phase, doctors were asked the reasons for occurrence of errors. The contributing factors for errors were determined by distributing self-administered questionnaires to all doctors in wards. Following remedial measures, two more phases of data collection were carried out to evaluate its effectiveness.


First phase data collection detected 69 prescription errors out of 962 prescriptions (7.17%). Most (88%) prescription errors involved houseman doctors and generally involved antibiotics (31.8%). Surveys revealed that the most common problem faced by doctors was unsure of dosage regime (42.4%).

Strategies for Improvement

Remedial actions carried out included promotion of Drug Information Services, distribution of dosage mini cards to wards, presentation of project findings to the Head of Departments and also the distribution of pocket size reference dosage cards to houseman doctors.

Effects of Change

Following remedial actions, the percentage of prescription error dropped from 7.17% to 2.25% and later slightly increased to 2.94%.

The Next Step

“Medication ordering training” needs to be incorporated during IT orientation for new doctors. Also, “default dosing for commonly prescribed drugs” was proposed. Although CPOE reduced the number of prescription errors, more human effort and IT intelligence will be needed to prevent prescription errors.

OP-05 Reducing E-Prescription Error in a Hospital In-patient Pharmacy



-21st

October 2011

6

Tan PL, Azhari Wasi NA, Dhillon HK, Buang A, Sulaiman CZ, Mohd Zakaria IE, Tan WC, Poopaladurai D. Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.


Oncology patients and/or their caregivers were subject to the inconvenient process of obtaining special formulary cytotoxic drugs due to the different locations of cytotoxic drugs in University Malaya Medical Centre (UMMC). The process also caused delays in reconstitution of drugs and thus, administration time. Therefore, the aim of this project was to re-engineer the current process to increase patients‟ satisfaction.


Reduction in time spent by patients to obtain cytotoxic drugs (<10 minutes)

Reduction in time delay in reconstitution of cytotoxic drugs (<5 minutes)

Decrease in patient‟s inconvenience (≥80%)


Time spent and delay as well as patients‟ feedback were collected from 25 January to 26 February 2010 (5 weeks). The effectiveness of the new process was evaluated by monitoring the time and patient satisfaction from 1 March to 2 April 2010 (5 weeks) measured using a simple questionnaire with a scale from 1-5 (1=very easy, 5=very difficult).


The time spent per patient and the delay in reconstitution was 18.5 minutes per patient (N=216), giving a difference of 8.5 and 13.5 minutes respectively from the standards set. A total of 143 feedbacks were received, with 48.9% positive feedback (patients felt easy to obtain the drugs), hence a 31% gap from standard.

Strategy for Change

Centralised storage of special formulary cytotoxic drugs in a sterile complex and the change in patients‟ flow were initiated. Fax was used as a means of communication to initiate reconstitution.

Effects of Change

Time spent on obtaining cytotoxic drugs per patient was reduced to zero, whereas delay in reconstitution was reduced to 3.7 minutes per patient (a reduction of 14.8 minutes). A total of 140 feedbacks were received with 84.3% being positive(an increase of 35.4%).

The Next Step

Implementation of the new process had successfully decreased patients‟ inconvenience. One stop payment in Pharmacy and online protocols will further simplify the process of care.

OP-06 Re-Engineering the Process of Obtaining Special Formulary Drugs by Oncology Patients



-21st

October 2011

7

Norasikin M, Zaitun I, Roslenda M, Mazliza M, Rubiah L, Masriah M. Pejabat Kesihatan Pontian, Johor.


Anemia semasa hamil boleh menyebabkan morbiditi dan mortaliti kepada ibu hamil dan anak yang dikandung. Prevalens anemia di kalangan ibu hamil Daerah Pontian masih tinggi iaitu di antara 25% hingga 33% dari tahun 2001 hingga tahun 2003.


Menurunkan prevalens anemia di kalangan ibu hamil pada usia kandungan 36 minggu. Standard yang ditetapkan adalah kurang dari 10 %.


Kajian irisan lintang telah dijalankan pada bulan Januari hingga Disember 2004. Seramai 671 ibu hamil telah dipilih secara rawak di kalangan yang bersalin pada tahun 2003.Borang soal selidik dan kad ibu hamil digunakan untuk mengetahui faktor yang mempengaruhi anemia di kalangan ibu hamil.

Analisis dan Interpretasi

Hasil kajian menunjukkan daripada 671 responden, seramai 224 (33.4%) mengalami anemia bagi tempoh satu tahun. Hanya faktor klinik kesihatan, status pekerjaan, cara kelahiran dan cara pengambilan bersama hematinik mempengaruhi status anemia di kalangan ibu hamil (p<0.05).


Penambahbaikan dibuat bermula tahun 2005. Hasil kajian menunjukkan faktor suri rumahtangga sepenuh masa dan kelahiran forsep mempengaruhi anemia. Oleh itu, kad ibu hamil yang ada faktor tersebut ditanda biru supaya lebih diberi perhatian. Mereka diberi keutamaan dari segi pendidikan kesihatan berkaitan pengambilan hematinik dan sentiasa dibuat pemantauan status Hemoglobin secara berkala. Penekanan dari segi kaedah pengambilan hematinik diberi kepada ibu hamil. Risalah dan poster anemia disediakan dan diedarkan ke semua 8 buah klinik kesihatan dan 33 buah klinik desa. Sesi pendidikan kesihatan diberikan kepada anggota kejururawatan. Inovasi cakera anemia telah dihasilkan bagi memudahkan anggota kesihatan terutama anggota baru mengendalikan kes anemia supaya kes tersebut dapat dipulihkan. Cakera anemia adalah cakera kertas mengandungi panduan pengurusan anemia ibu hamil.


Kesan perubahan dinilai melalui laporan HMIS tahun 2007 bagi Daerah Pontian. Didapati prevalens anemia hanya dapat dikurangkan daripada 33.4% pada tahun 2004 kepada 15.5% pada tahun 2007. Kitaran QA kedua pada tahun 2008 mendapati anggota kejururawatan kerap berpindah keluar dan kurang pendedahan mengenai pengurusan anemia berlaku di kalangan anggota kejururawatan. Strategi penambahbaikan difokuskan kepada pendidikan kesihatan, penggunaan cakera anemia, audit dan penyeliaan anggota secara berterusan serta pelan tindakan spesifik diwujudkan. Penilaian semula melalui laporan HMIS pada tahun 2010,mendapati prevalens anemia di kalangan ibu hamil pada usia kandungan 36 minggu menurun kepada 7.8%. Kajian menunjukkan sebanyak 70.8% anggota kejururawatan mempunyai pengetahuan sangat memuaskan dan 29.2% memuaskan.

Langkah Seterusnya

Memperkenalkan cakera anemia kepada anggota kejururawatan di lain daerah dan mewujudkan kit hematinik semasa kursus perkahwinan.

OP-07 Menurunkan Kejadian Anemia di Kalangan Ibu Hamil pada Usia Kandungan 36 Minggu



-21st

October 2011

8

Rosdi MZ, Dang CC, Ku SC, Norshazareen AM, Lim CW, Tan BL. Pharmacy Department, Melaka Hospital, Melaka.


Non-adherence to blood sampling time may lead to inaccurate recommendation of drug dosage or frequency given by the pharmacist and this may then lead to drug toxicity or inadequate therapeutic response.


Adherence to blood sampling time was defined as blood samples that are taken according to the Therapeutic Drug Monitoring (TDM) Guidelines on Blood Sampling Time. The Standard of Good Care was set with the target of adherence to blood sampling time being more than 90%.


A data collection sheet was prepared and TDM forms were screened. TDM forms received from all the wards of Melaka Hospital were included except from Psychiatric Wards, Outpatient Clinics and other hospitals or polyclinics. Data needed were transferred from TDM forms to data collection sheet. The same process was done for TDM forms received in August 2009, February 2010 and August 2010.


Percentage of adherence to blood sampling time was 45.9% before the remedial measures.

Strategy for Change

A series of talks were given to pharmacists, nurses and doctors. A „reminder sticker‟ was introduced to the current setting. Besides, TDM Guidelines on Blood Sampling Time was distributed to all the wards in Melaka Hospital.

Effects of Change

The adherence had increased to 61.8% after the first remedial measure and had further improved to 88.6% after the second remedial measure.

The Next Step

All remedial measures taken were shown to improve the adherence to blood sampling time for TDM in Melaka Hospital. However, the target set in Standard of Good Care has not been achieved yet. More studies will be conducted to further improve the current system.

OP-08 Improving Adherence to Blood Sampling Time for Therapeutic Drug Monitoring in a Government Hospital



-21st

October 2011

9

Zalina I, Wan Asim WA, Idris L, Aida Fadriah M, Wan Raihana WA,Yang SA, Kumar J, AlHindi R, Gisely V. BRAINetwork Centre for Neurocognitive Science, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan.


There was a daily loss of about 0.9 hours of productivity due to decreased mental alertness. Many nurses utilised social networking sites, tea breaks or personal discussions to refresh their minds and find it difficult to get back to their job. An opportunity existed for creating a cheap and an effective way of improving alertness without sacrificing money, time or productivity.

Key Measures of Improvement

The BRAINwaves System was expected to improve alertness, productivity, focus and wellness by 50%.


The Blue Ocean Strategy and Prashnig‟s Working styles analysis were used to identify neurocognitive health issues of 70 administrators and nurses in the Intensive Care Unit and Operating Theatres of Universiti Sains Malaysia (USM) between January and June 2011.


Fifty percent of respondents indicated that decreased alertness was a major neurocognitive problem while lack of socialisation, lack of reward and recognition and unsatisfactory facilities scored 20%.

Strategy for Change

The BRAINwaves System was developed and an interventional study was carried out. Respondents were randomly selected for confirmatory electroencephalography tests. Neurocognitive changes were also assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB).

Effects of Change

BRAINwaves improved alertness, productivity, focus and wellness by 85%, lowered costs by 96%, with projected savings of RM122 000/ year. Focus group studies indicated that BRAINwaves met current market needs and created value innovation by improving mental alertness across five different domains. It is highly specific yet diverse enough to cut across communities, age groups and cultures.

The Next Step

The BRAINwaves System is highly effective and will be applied to all administrators and nurses in USM as part of a management effort to improve productivity in the workplace by improving neurocognitive health.

The BRAINwaves System: Development of a Mind

Stimulating System to Improve Neurocognitive Health by

Increasing Alertness in the Workplace

OP-09



-21st

October 2011

10

Nancy B, Sania L, Diviki T, Anita M, Zabidah J, Rusti T, Jockina M. Hospital Wanita dan Kanak-Kanak, Kota Kinabalu, Sabah.

Pemilihan Peluang Untuk Penambahbaikan

Sebilangan 20-40% pesakit yang dimasukkan ke Wad Obstetriks & Ginekologi (O&G) dan 100% pesakit yang menjalani pembedahan, dirawat dengan infusi intravena (IV). Hasil audit bagi tiga tahun berturut-turut 2008-2010 menunjukkan pencapaian Wad O&G hanyalah mematuhi Standard Operating Procedure (SOP) sebanyak 65-69% dan tidak mencapai sasaran yang ditetapkan oleh Unit Kejururawatan, Jabatan Kesihatan Negeri Sabah.


Indikator yang dikenalpasti adalah peratusan kepatuhan penjagaan perawatan pesakit dengan infusi IV mengikut SOP dengan standard lebih 80%.


Semua Jururawat U29 di Wad O&G dan pesakit dengan infusi IV diambil sebagai sampel kajian. Kajian dilaksanakan dari 1 hingga15 Disember 2010. Borang soal selidik digunakan untuk mengkaji pengetahuan jururawat berkaitan perawatan pesakit dan menilai keberkesanan pemberian penerangan kepada pesakit sebelum dan semasa pemasangan infusi IV. Senarai semak digunakan untuk menentukan dan memerhati cara perawatan yang diberikan.


Didapati daripada sejumlah 110 jururawat, 20% dikenalpasti kurang pengetahuan berkaitan cara mengira titisan infusi IV. Faktor lain mempengaruhi ketidakpatuhan terhadap perawatan pesakit infusi IV adalah beban tugas yang tinggi, tiada semakan regim, melayan pesakit, kurang pemantauan, regim kurang jelas dan salah pengiraan titisan/kalibrasi oleh jururawat. 75% pesakit tidak diberikan penerangan sebelum pemasangan infusi IV.


Strategi yang dilaksanakan termasuklah mengadakan sesi ceramah dan pembelajaran berterusan dari wad ke wad berkaitan Prosedur Infusi Intravena; bengkel memantap cara pengiraan infusi IV regim; program berstruktur kepada jururawat lantikan baru atau baru pindah dan memantapkan kecekapan pemantauan klinikal. Mesyuarat bersama Ketua Jabatan berkaitan penyediaan regim tepat dan jelas turut diadakan. Memantapkan pemberian penerangan kepada pesakit mengenai penjagaan infusi IV secara tidak langsung memberikan peranan/kuasa kepada pesakit untuk melibatkan diri bersama jururawat dalam menjaga infusi IV.


Selepas enam bulan, pelan penambahbaikan telah meningkatkan peratusan kepatuhan terhadap perawatan pesakit dengan infusi IV daripada 69% meningkat kepada 87% dan melepasi sasaran yang ditetapkan.

Langkah Seterusnya

Sesi pembelajaran berterusan, pemantauan indikator setiap 6 bulan dan berterusan untuk pengekalan dan peningkatan kepatuhan kepada SOP. Jururawat perlu komited, supaya ia menjadi amalan budaya perawatan.

Meningkatkan Peratusan Kepatuhan Terhadap Perawatan Pesakit dengan Infusi Intravena di Wad Obstetriks & Ginekologi

OP-10



-21st

October 2011

11

Yuzainov A, Nurul Khairiyah K, Norul Akhma AH, Rahmah N, Norraihan H, Suriwati I. Hospital Seberang Jaya, Penang.


A retrospective analysis in the Obstetrics and Gynaecological (O&G) Department, Seberang Jaya Hospital revealed that only 24% of babies with fetal distress were delivered within 30 minutes (via caesarean section) from July to December 2007. This can result in an increase in perinatal morbidity and mortality. This study intended to improve the rate of babies delivered with fetal distress within 30 minutes.


This study aimed to re-engineer the process involved from decision making to delivery of baby. A standard of more than 70% of babies delivered within 30 minutes was set.


A prospective study (pre-remedial) was carried out from April to May 2008. The staff were assessed on their knowledge on the urgency to deliver babies with fetal distress using self-administered questionnaires. A data sheet on the time sequence from decision for caesarean section till delivery of baby was designed.


6.25% of babies were delivered within 30 minutes during the pre-remedial study. Delay in preparing and sending patient to OT was among the major contributing factors identified.

Strategy for Change

Seminars and drills were carried out to improve staff knowledge on the urgency to prepare patient for caesarean section. Delay in sending patients was attributed to lengthy report writing. Hence a simplified nursing report form was created to expedite the process. A caesarean section kit was also innovated to expedite preparation of patient.

Effects of Change

The rate of babies with fetal distress delivered within 30 minutes increased from 6.25% (pre-remedial) to 46.9% (3rd cycle). There was also an improvement on staff knowledge from 18% (pre-remedial) to 95% (3rd cycle). ABNA was reduced from 63.8% to 23.1%.

The Next Step

The simplified nursing report form and caesarean section kit were adopted for other cases of caesarean section. The improvement in the re-engineering of the work process will also be shared with other hospitals in our country.

Improving Time Interval from Decision to Caesarean Delivery for Fetal Distress Cases

OP-11



-21st

October 2011

12

Nor Jumizah AK, Lim KY, Faridah MY, Wan Mazlina WR, Maziati M, Suhainiza S, Norleeza MN. Department of Obstetrics and Gynecology, Kemaman Hospital, Terengganu. Selection of Opportunities for Improvement

2006-2008 statistics had shown that post partum haemorrhage (PPH) was one of the major problems faced by the Obstetrics and Gynaecology Department in Hospital Kemaman, which contributed towards the increased morbidity and mortality rate of pregnant mothers. The aim of this study was to identify the contributing factors and to reduce the incidence of PPH in Lower Segment Caesarian Section (LSCS).


We set a standard of LSCS without PPH at 90%.


A cross sectional clinical study was carried out from July 2008 to December 2009. Data were obtained from maternal notes and questionaires. The rate of LSCS without PPH were calculated by incident of LSCS without PPH divided by total LSCS multiplied by 100. The research tool used was self administered questionnaire.


Our verification study showed the incidence of LSCS without PPH was only 83.5%. PPH in LSCS was associated with delay in calling for help by the junior doctors, surgery related factors, uterine factors and inappropriateness of measures taken to prevent PPH as well as lack of staff knowledge and urgency.

Strategy for Change

The remedial measures taken were training module on LSCS for medical officers, emphasis on early call for help by medical officers, LSCS training module, CME sessions for doctors and paramedics and application of safe surgery protocol. Patients were prepared for surgery in accordance to their risk factors and cases were delegated to surgeons based on risk, seniority and experience of the surgeon.

Effects of Change

The incidence of LSCS without PPH increased from 83.5% to 92.5 %.There was an increased in awareness of calling for help early and knowledge of staff had also improved .

The Next Step

The remedial measures carried out had been effective, thus it shall be applied constantly and improvement will be made along the way. Our next aim is to carry out an observational study on „Surgery related reasons of PPH in LSCS‟ which will assist us in improving the remedial actions implemented in this QA study.

Increasing Lower Segment Caesarian Section without Post Partum Haemorrhage

OP-12



-21st

October 2011

13

Nor Azila MI, Shuaita MN, Uthayalaxmi N, Ahmad Nazifi S, Toh LS, Mohd Azrul Z, Nor Izzah AS. Kuala Langat District Health Office, Selangor.


The management of asthma in health clinics under Kuala Langat District Health Office was found to be inadequate based on the findings from the National Indicator Approach (Appropriate Management of Bronchial Asthma). Further evaluations disclosed that the assessment of patients during follow up was suboptimal. This project aimed to focus and improve the assessment of asthmatics in Kuala Langat health clinics.


Assessment of patients during follow-up, adequacy of assessment tools in the clinic and sufficient knowledge amongst the health care providers were the key measures for improvement in this QA study. The target for the DSA QA indicator is more than 80% of patients should be optimally assessed during follow up.


The study was conducted from September 2009 to May 2011 comprising pre-intervention period and four cycles post-intervention. The records of all asthmatics attending clinic during the identified study periods were selected. Audit was done using a special checklist to check availability of assessment tools in the clinics and clinical assessment of asthmatics. A self-administered questionnaire was used to evaluate the knowledge of all healthcare providers in the clinics.


Initial evaluation showed only 2% of patients was optimally assessed during follow-up in the health clinics.

Strategy for Change

The establishment of Asthma Record Book, local implementation protocol, the innovation of the “ASTHMA KIT”, the provision of asthma diary to all asthmatic patients and workshops on “Assessment & Management of Asthmatic Patients” for all health care providers had been identified as the remedial measures. Following each cycle, reinforcements were done in the form of individual coaching or group discussion.

Effect of Change

Post-intervention study revealed noticeable improvement of the DSA indicator from 2% to 49% in the 1st Cycle, 68% in 2nd Cycle, 69% in the 3rd Cycle and went up to 79% in the 4th Cycle.

The Next Step

Regular audits are vital to sustain the results obtained. Further interventions in other components of asthma management need to be implemented with the ultimate goal of improving patients‟ asthma control.

Improving the Percentage of Asthmatics Receiving Optimal Assessment During Follow Up in Health Clinics

OP-13



-21st

October 2011

14

Suzaini MD, Junaidah I, Norhayati S, Nur Hazwani R, Rosnani R. PKD Kangar, Perlis.


Di Perlis, peratus ibu hamil dengan anemia pada 36 minggu melebihi standard Kementerian Kesihatan Malaysia. Pengurusan kes yang kurang sistematik dan tidak mengikut Clinical Pactice Guideline dikenalpasti sebagai penyumbang kepada masalah.


Meningkatkan pengurusan yang efektif (mengikuti kesemua 4 elemen dalam strategi penambahbaikan) dan mengurangkan peratus ibu hamil dengan anemia pada 36 minggu kepada kurang dari 26% (mengikut KPI Kesihatan Keluarga).


Tiga kajian verifikasi dijalankan pada 2009 menggunakan kad KIK/1(b)/96 melibatkan 151 ibu hamil.


Hasil kajian mendapati pengurusan yang efektif hanya kepada 51 (33.8%) kes. Pemberian zat besi (iron) profilaksis secara oral adalah 9.4% dan terapeutik 24.4% sahaja. Penyiasatan Iron Deficiency Anaemia (IDA) dilakukan untuk 47 (31%) kes. Hanya 11 (7.3%) ibu menerima rawatan parenteral. Kajian KAP mendapati 60% anggota kejururawatan kurang arif mengenai pengurusan kes anemia


Empat penambahbaikan dilaksanakan bermula April 2010: (i) Mewajibkan pengesahan IDA atas kes anemia (ii) Pemberian profilaksis zat besi secara oral (Ferrous Fumarate 200 mg b.d) kepada ibu dengan Hb normal semasa booking (iii) Memulakan rawatan terapeutik (Ferrous Fumarate 400 mg b.d) serta-merta apabila Hb<11 gm/dL. (iv) Rawatan zat besi secara parenteral iaitu Intravenous Drip Infusion (IDI) untuk semua kes yang gagal rawatan oral selepas 2-4 minggu, sah kes IDA dan tiada kontraindikasi.


Kajian semula ke atas 320 ibu hamil pada 36 minggu dilakukan selepas 6 bulan strategi penambahbaikan di implementasikan. Didapati, pengesanan kes anemia meningkat 17.1% di trimester ke-2 dan menurun 14.6% di trimester ke-3.Ujian pengesahan IDA mencapai 76%. Semua ibu hamil menerima zat besi secara oral dengan 210 (65%) kes pada dos profilaksis dan selebihnya dimulakan dos terapeutik. Sebanyak 103(32.2%) gagal rawatan oral dan menerima parenteral iron. Hanya 82 kes penerima rawatan parenteral boleh dianalisis disebabkan kekurangan data. Didapati 72(87.8%) kes menunjukkan peningkatan Haemoglobin (Hb) selepas 1-2 minggu infusi iron. Kajian menunjukkan penurunan 9.0% kes anemia dan peningkatan 8.8% kes tanpa anemia berbanding sebelumnya.

Pengurusan anemia yang efektif meningkat sebanyak 66% untuk strategi (i) dan (ii). Ujian pengesahan IDA meningkat 45%. Peratus ibu hamil anemia tahun 2010 menurun dan mencapai standard yang ditetapkan iaitu 26% dan ini merupakan penurunan ABNA sebanyak 4.0%.

Langkah Seterusnya

Meneruskan kesemua strategi penambahbaikan dengan penekanan kepada rawatan parenteral secara IDI untuk kes yang layak.

Meningkatkan Pengurusan yang Efektif bagi Ibu Hamil dengan Anemia di Klinik Kesihatan

OP-14



-21st

October 2011

15

Noor Mariati O, Siti Masyitah MT, Noorulhuda S, Lee LG, Azizah M, Khairul Anuar M, Norsiah MN. Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang.


Item bukan ubat perlu dipesan sebulan sekali. Peratusan pesanan luar jangka yang tinggi disebabkan oleh kelewatan penerimaan barang daripada pembekal, stok dalam stor tidak mencukupi untuk dibekalkan, tiada senarai alat dan senarai piawai alat dari unit pemesan, tiada sistem pemantauan stok yang sistematik, ruang penyimpanan yang terhad dan penyusunan barang yang tidak sistematik serta pesanan bulanan tidak mengikut jadual. Objektif kajian ialah mengurangkan kekerapan pesanan luar jangka dengan mengenalpasti kekerapan pemesanan luar jangka, faktor penyumbang dan menentukan langkah penambahbaikan serta menentukan keberkesanan langkah yang diambil.


Indikator kajian ialah peratus pesanan luar jangka yang diterima dengan standard kurang dari 20%


Data pesanan luar jangka diperolehi dari buku daftar pesanan. Maklumat lain diperolehi melalui soal selidik dan pemerhatian menggunakan borang pengumpulan data.


Peratus pesanan luar jangka sebelum penambahbaikan dilakukan ialah 60.7%. Faktor penyumbang utama kekerapan pesanan luar jangka ialah senarai piawai minima dan maksima item bukan ubat dari unit pemesan iaitu 90% dan pesanan tidak mengikut jadual sebanyak 100%.


Empat strategi telah dilaksanakan iaitu mengadakan taklimat pengurusan stor kepada pegawai yang menjaga unit/wad terlibat, penguatkuasaan jadual pesanan bulanan, mewujudkan senarai minima dan maksima item bukan ubat dan pemantauan stor secara berkala.


Hasil langkah penambahbaikan yang telah diambil adalahpenurunan pesanan luar jangka dari 60.7% ke 33.3%. Ini masih tidak mencapai standard yang ditetapkan iaitu 20%.

Langkah Seterusnya

Kajian lanjutan akan diteruskan untuk mengenalpasti faktor lain yang boleh menyebabkan peratusan pesanan luar jangka yang tinggi serta langkah penambahbaikan yang perlu diambil untuk mengatasinya.

Mengurangkan Kekerapan Pesanan Luar Jangka dari Unit Pemesan bagi Item Bukan Ubat di Unit Perolehan dan Pembekalan

OP-15



-21st

October 2011

16

Shakirin SR, Izrul Azwa ML, Tan SY, Cheah SY, Wong MK, Chiew CW. Department of Pharmacy, Labuan Hospital,Wilayah Persekutuan Labuan. Selection of Opportunities for Improvement

Inappropriate Warfarin dose was associated with higher bleeding events. Only 38.7% individual International Normalised Ratio (INR) values of Warfarin patient are within targeted INR range. Collaboration between physicians and pharmacists, who managed Warfarin Medication Therapy Adherence Clinic (MTAC), was introduced to closely monitor INR and counsel regarding drug-drug interactions, dietary intakes and lifestyle. This study aimed to improve targeted INR value of Warfarin patients with increased involvement of pharmacists.


Warfarin MTAC pharmacists in Labuan Hospital decided to set standard percentage of individual INR reading within the targeted therapeutic range of at least 50%.


23 patients were involved in this study. Their INR readings from June to November 2009 were obtained from their Bed Head Ticket (BHT). Pre intervention investigation found that lack of pharmacist involvement contributed to the non achievement of targeted INR value of Warfarin patients.


Of the 191 individual INR values from the 23 patients, only 38.7% were categorised as ”good”.”Good” is defined as values within the target. Prior to Warfarin MTAC, the following flaws were observed: there was no record of Warfarin counseling, proper documentation of INR reading in the BHT nor was there any standard Warfarin booklet given to patients. Supply of warfarin was obtained from the „Farmasi Klinik Pakar‟.

Strategy for Change

We have implemented a one-stop service centre of Warfarin MTAC. The patients‟ blood samples were taken by the pharmacist using Point-of-care (POC) instrument and Warfarin was supplied during the Warfarin MTAC session. Patients also received standard Warfarin booklets where INR values and Warfarin doses were recorded. Warfarin patients also received continuous individual counseling sessions.

Effects of Change

After implementation, the number of individual INR readings within target range increased from 38.7% to 55.9%.

The Next Step

The Warfarin MTAC pharmacists now aims to achieve improved patients‟ INR reading targeted above 70% in the pharmacy practice with regular assessments.

Role of the Pharmacist in Improving Targeted International

Normalised Ratio Value of Patients on Warfarin Therapy OP-16



-21st

October 2011

17

Rozaidah AK, Norlida AB, Fatimah A, Nor Azuwa J, Che Zakiah O, Dominica Rose JS Daniel. Department of Nursing and Intensive Care Unit, Taiping Hospital, Perak.


In caring for the critically ill, we do not want them to develop hospital-acquired complications. Ventilator Associated Pneumonia (VAP) is the commonest ICU associated infection accounting for 47% of all infections in ICU. Similarly in ICU of Taiping Hospital, it has been persistently high.


The Malaysian standard for VAP is 15.0/1000 ventilator days and our objective was to reduce it from 40.0 in the first half of 2009 to 15.0 in the same period in 2010.


This is a cross-sectional study involving all ICU patients from January 2009 to December 2010. Patients‟ data were collected through patients‟ case notes, admission book, check list, audit sheet and Malaysian Registry of Intensive Care (MRIC) report.


Five main contributing factors to VAP were identified and analysed. Compliance to Ventilator Care Bundle (VCB) was good (87 – 100%), yet the incidence of VAP was high (35 – 50/100 ventilator days).

Strategy for Change

We adopted a holistic approach which comprised increasing staff awareness and improving oral and bronchial hygiene as well as infection control practices. Our first intervention was to educate our staff through ICU level Workshops/CNE/CME sessions. Four hourly oral hygiene and measurement of cuff pressure per shift were made mandatory. Aerosol nebulisers were changed to Metered Dose Inhalers. The Ventilator Care Bundle (VCB) was reinforced with daily compliance audits. Each patient area was defined by a 1 meter red line drawn on the floor around each bed. All relevant departments were notified of tightened infection control in ICU through a letter via our hospital director and a notice to visitors was put up at the ICU entrance to inform them of how they could help.

Effects of Change

The incidence of VAP dropped to 5/1000 ventilator days between January to June 2010 and further to 2/1000 ventilator days. A sustainability study showed that this had reduced further to 0.5/1000 ventilator days, thereby reducing the risk of loss of lives and improving patients‟ safety.

The Next Step

All corrective interventions will be continued, improved and sustained through reinforcements and audits. A written oral care protocol will be created and incorporated into our ICU policy. The findings of this study will also be disseminated to other ICUs.

Reducing the Incidence of Ventilator Associated Pneumonia among ICU Patients

OP-17



-21st

October 2011

18

Jayashree M, Shahrul Bariyah A, Norsiah MN, Ruzita S. Klinik Kesihatan Pendang, Kedah.


Asma bronkial ialah masalah kronik melibatkan 4% penduduk Malaysia dan hanya 5% daripadanya terkawal. Faktor penyumbang utama ialah pengendalian, pemantauan dan teknik metered-dose inhaler (MDI) yang lemah. Daripada tahun 2007-2009, peratus asma bronkial terkawal di Daerah Pendang merosot daripada 49% kepada 39%. Penyumbang kepada fenomena ini ialah garispanduan sedia ada dari kementerian yang agak lama dan mengelirukan.


Meningkatkan peratus asma bronkial terkawal di daerah Pendang. Piawaian yang ditetapkan ialah 80%.


Kajian verifikasi dibuat ke atas 57 pesakit pada Mac 2009 melalui audit kad pesakit luar, soal-selidik serta temubual pesakit. Kajian tahap pengetahuan dilakukan ke atas anggota kesihatan yang mengendalikan kes asma bronkial melalui borang soalselidik. Kajian penambahbaikan pula dilakukan ke atas 62 pesakit pada Mac 2010 dan 42 anggota kesihatan yang terlibat.


Analisa sebelum penambahbaikan menunjukkan hanya 48% pesakit asma bronkial mempunyai bacaan peak expiratory flow rate (PEFR). 82% pesakit menggunakan MDI dan hanya 41% boleh menunjukkan teknik MDI yang betul. Hanya 31% anggota kesihatan mempunyai pengetahuan yang mencukupi. Kesemua faktor ini menyumbang kepada pengawalan yang rendah iaitu 39% pada 2009.

Strategi penambahbaikan

i) Buku pengurusan asma bronkial diwujudkan sebagai pendekatan sistematik.

ii) Penglibatan Pegawai/Pembantu Perubatan, Pegawai Farmasi dan Asthma Educator.

iii) Sesi pendidikan berterusan bagi anggota kesihatan.

iv) Pendidikan pesakit.

Kesan penambahbaikan

Jumlah pesakit mempunyai bacaan PEFR meningkat ke 87% dan 71% pesakit boleh menunjukkan teknik MDI yang betul. Pengetahuan anggota kesihatan meningkat kepada 86%. Kesemua faktor ini meningkatan tahap pengawalan asma bronkial kepada 61% pada 2010.

Langkah Seterusnya

Kajian perlu diperluaskan kepada golongan kanak-kanak serta kesinambungan pengendalian berasaskan Global Initiative For Asthma (GINA) diperkenalkan di KK Pendang. Projek ini telah mengorak langkah bagi Daerah Pendang menuju ke arah pengawalan asma bronkial yang optima.

Meningkatkan Peratus Asma Bronkial Terkawal

OP-18



-21st

October 2011

19

Gadung A, Christina BL, Adeline WSF, Juliana H, Hilda B, Iya R. Kuching Divisional Health Office, Sarawak.


The incidence of Severe Neonatal Jaundice (SNNJ) in Kuching District increased from 119.3 per 10,000 live births in 2005 to 123.3 per 10,000 live births in 2008, which was above the standard of the National QAP Indicator of 100 per 10,000 live births.


The objective of this study was to reduce the incidence of SNNJ in Kuching District from 121.34/10,000 Expected Live Birth (ELB) to below 100/10,000 Expected Live Birth (ELB).


This study used a cross sectional design covering a period of six months. The sample comprised 113 nurses of all categories working in urban and rural maternal and child health clinics in Kuching District. Tools used in the study were self-administered questionnaires in English and Bahasa Malaysia.


The pre-intervention survey on nurses showed that only 56.6% were able to identify the risk factors for jaundice; 94.6% were able to define jaundice; 41.5% were able to detect jaundice while 70.8% knew sign of kernicterus. As for normal post natal nursing schedule (Day 1,2,3,4,6,8,10 and day 20 post natal), only 40.7% were able to practice the schedule while only 69.0% were able to give advice on management of jaundice.

Strategy for Change

The interventions were Continuing Nursing Education sessions which included new nursing formats and new reporting procedures. Vehicles were also provided for home nursing.

Effects of Change

Post intervention; 63.2% of nurses were able to identify the risk factors causing jaundice; 97.2% were able to define jaundice while 97.2% were able to detect jaundice and 88.6% know sign of kernicterus. In term of practising recommended post natal nursing schedule, it had increased to 49.9 % while 92.0% were able to give advice to mother on management of jaundice. Second day postnatal nursing increased from 16.7% to 65%. The incidence of SNNJ dropped to 78 per 10,000 live births in 2010.

The Next Step

The interventions helped to improve the knowledge and practice of recommended measures to detect neonatal jaundice early. Stronger emphasis will be placed on using the new reporting procedures and new nursing sheets. Continuous monitoring through regular nursing audits is also essential to reduce the incidence of SNNJ. Provision of vehicles for all busy maternal and child health clinics for home nursing care is to be continued.

Value Added Features

The interventions undertaken is effective and to be included for National Indicator Approach (NIA).

OP-19 Reducing Incidence of Severe Neonatal Jaundice



-21st

October 2011

20

Subramaniam T1,Fudziah A1, Jeyaindran S2, Suliyana Y1, Lim SC1, Chong MF1, Cheng PL1, Teng SC1. 1Department of Pharmacy, Kuala Lumpur Hospital. 2Department of General Medicine, Kuala Lumpur Hospital, Wilayah Persekutuan Kuala Lumpur.


Non-achievement of International Normalised Ratio (INR) among warfarinised patients results in poor clinical outcomes and increased healthcare cost.


The key measures for improvement were percentage of INR readings within target range (2 - 3), patients‟ warfarin therapy knowledge and clinic waiting time.


The selected measures were assessed both in the pre and post-remedial actions phase. Five INR levels of 331 patients were collected. A survey was conducted to assess the clinic waiting time and a questionnaire was administered to assess patients‟ knowledge of warfarin therapy.


Almost 50% (827 readings) of the INR levels did not meet the INR target. The average clinic waiting time per patient among 100 patients was 202 minutes and these patients were only able to answer on average 10 out of 18 questions correctly.

Strategy for Change

The implementation of the remedial action is an on-going process and the remedial actions were implemented in three phases based on process, knowledge and attitude. The process in terms of blood taking method and clinic appointment was improved. Education sessions for both patients and healthcare personnel were provided to improve their knowledge on warfarin therapy. A drug consumption calendar was given to every patient to encourage positive attitude towards warfarin therapy. Improved dosing method was used in Phase 2 whereas patients‟ reminders were used in Phase 3.

Effects of Change

The percentage of INR levels within target range increased by 16 % upon the implementation of the remedial actions. The average clinic waiting time was reduced by 51.5% to 98 minutes. Average warfarin therapy knowledge questions answered correctly improved by 40%. In terms of the satisfaction, 90% of the patients were satisfied with the time, information provision and overall clinic management. In Phase 2, the percentage of INR reading within range for the selected patients improved from 60% to 72%. Phase 3 is in progress.

The Next Step

Quality improvement in managing warfarinised patients is a continuous, multi–disciplinary, patient oriented approach. These clinic-based remedial actions will be expanded to Fridays. We will explore the possibility of conducting a pharmacoeconomic study.

Achieving International Normalised Ratio Targets and Satisfaction of Warfarinised Patients

OP-20



-21st

October 2011

21

Adeline ML Khaw, Chariya Eh Chot, Ng SL, Rosli A. Department of Ophthalmology, Hospital Taiping, Perak.


Diabetic Retinopathy (DR) is a microvascular complication of patients with diabetes. Those who have Severe Non-Proliferative DR (Severe NPDR) are at high risk (one year risk of 50.2%) of progressing to Proliferative DR (PDR) with subsequent poor visual outcome due to vitreous haemorrhage and/or retinal detachment. This study was carried out to identify the contributing factors, develop effective remedial measures and thus, delay the progression of this potentially blinding complication.


We aimed to reduce the above percentage of 50.2% to 20%, based on the target set by our department.


This project was divided into 4 parts. A retrospective analysis was done over a 2 year period (January 2007 to December 2008) to identify contributing factors (n=12). Remedial measures have been carried out since January 2009. Evaluation on its effectiveness was carried out from March 2009 to April 2010 (n=20). A sustainability review was held from June 2009 to July 2010 (Part 1, n=20) and August 2010 to April 2011 (Part 2, n=15).


Four contributing factors were identified namely, long waiting time for new cases, poor glycemic control, low number of referrals to nearest clinics for better glycemic control and delay in initiating Laser Treatment.

Strategy for Change

Remedial measures included starting Laser Treatment at Severe NPDR stage, strict supervision of learning doctors during Laser Treatment, giving appointment to new patients with diabetes within 6 weeks, lifestyle modification counselling and referring of patients with poor glycemic control (FBS > 10mmol/l) to the nearest clinic. These measures involved all doctors and paramedics in our department.

Effects of Change

There was a significant reduction in the percentage of clinical progression of Severe NPDR cases to PDR stage from 67% in 2007, 70% in 2008 to 10% in March 2009 until April 2010. A lower percentage of 5% was recorded in our Sustainability Review period (Part 1) and similarly 6% in Part 2.

The Next Step

This project had raised awareness among our doctors to be more vigilant in DR cases. We had started introducing monthly Fundus Camera screening programme in nearby government clinics.

PP-01

Reducing the Percentage of Clinical Progression of Severe Non-Proliferative Diabetic Retinopathy Cases to Proliferative Diabetic Retinopathy Stage Over 1 Year in an Ophthalmology Department



-21st

October 2011

22

Azraei R, Ganggaraj A, Abdul Hamid MD. Jabatan Kesihatan & Alam Sekitar, Dewan Bandaraya Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.


Tinjauan yang telah dijalankan mendapati kebanyakan pengusaha premis makanan di Wilayah Persekutuan Kuala Lumpur telah membuang sisa minyak masak terpakai ke dalam longkang dan saliran awam. Senario ini akan mengundang banyak implikasi negatif terhadap kesihatan persekitaran.


Objektif program adalah mengurangkan pencemaran sisa minyak masak dan lemak di dalam longkang dan saliran awam serta membantu pengusaha restoran dan kedai makan melupuskan sisa minyak masak terpakai dengan sempurna. Indikator yang dikenalpasti adalah tiada lagi aduan awam yang berkaitan dengan pencemaran longkang atau saliran dan peningkatan isipadu kutipan sisa minyak masak oleh pengusaha kedai makan. Piawaian yang dikenalpasti adalah berdasarkan pemerhatian fizikal iaitu kehadiran lapisan filem minyak dan lemak atas permukaan air dan di tepi dinding longkang.


Kajian verifikasi data dibuat dari bulan Januari hingga Jun 2011. Lokaliti data merangkumi kawasan di sekitar Jalan Bukit Bintang, Jalan Alor, Kepong, Jalan Kelang Lama, Mont Kiara, dan Bangsar. Pengumpulan data adalah melalui rekod dan laporan kutipan sisa minyak masak terpakai dari premis makanan oleh kakitangan Dewan Bandaraya Kaula Lumpur dan panel swasta yang dilantik.


Pada tahun 2010 (Januari hingga Jun) 19, 212kg sisa minyak telah dikutip. Manakala pada tahun 2011 (Januari hingga Jun) 27, 446kg sisa minyak telah dikutip. Kadar peningkatan peratusan jumlah kutipan (kg) adalah sebanyak 42%. Peningkatan sebanyak 42% ini menunjukkan tahap keberkesanan program telah diyakini sepenuhnya.


Suatu inovasi telah dikenalpasti bagi mengatasi masalah ini berserta peluang penambahbaikan yang berterusan. Bagi memastikan keberkesanan usaha ini, Dewan Bandaraya Kuala Lumpur (agensi kerajaan) akan menjalinkan usahasama secara 3 hala dengan kontraktor kutipan (agensi swasta) dan pengusaha kedai makan (komuniti). Selain itu, khidmat nasihat juga diberikan dari semasa ke semasa kepada para pengusaha kedai makan yang belum lagi mempraktikkan kaedah ini.


Impak positif program ini adalah tiada lagi pembuangan sisa minyak ke dalam longkang dan saliran awam oleh pengusaha kedai makan. Walaubagaimanapun, apa yang paling penting ialah program ini mampu membantu para pengusaha kedai makan/pusat penjaja untuk melupuskan sisa minyak masak dengan sempurna dan terurus.

Langkah Seterusnya

Pencemaran longkang dan saliran awam dapat diatasi dengan lebih baik dan mampu menjanjikan pulangan yang „bersih‟ terhadap persekitaran alam semulajadi khususnya. Di samping itu, suatu keseimbangan ekologi antara manusia dan alam sekitar juga mampu diperolehi kerana sisa minyak masak yang terpakai boleh dikitar semula untuk penghasilan biodiesel yang berguna untuk keperluan manusia amnya.

PP-02 Mengurangkan Pencemaran Longkang dan Saliran Awam oleh Sisa Minyak Terpakai



-21st

October 2011

23

Hiew CY, Lee ML. Department of Pharmacy and Department of Paediatrics, Tuanku Ja’afar Hospital, Seremban, Negeri Sembilan.


Medication administration errors are common occurrences in any hospital setting especially in a paediatric ward. This is because of the different doses required by the paediatric patients due to the differences in their weight and age. This study aimed to identify the common medication errors that occur in a general paediatric ward and measures that can be implemented to reduce these errors.


The Pharmacy Department had targeted to reduce any type of medication errors to 0%.


An audit was done in the general paediatric ward of Tuanku Ja‟afar Hospital, Seremban from November 2008 to November 2009. The audit was done using a pre-prepared checklist produced by the Pharmacy Department. A pharmacist observed nurses when they prepared and administered medications. There were 3 cycles in this audit. 100 medications consisting of 50 oral and 50 intravenous, were conveniently chosen for each cycle. Interventions were done after cycle 1.


The percentage of errors for intravenous drug administration was 34% while for oral drug administration was 38%.

Strategy for Change

Periodical briefings about medication administration were given to new staff nurses and a pharmacist would randomly countercheck medication administration by selected nurses.

Effect of Change

Both of the intravenous arm and oral arm of the study showed a remarkable reduction in the number of „near misses‟. The percentage of errors for intravenous drug administration was reduced from 34% to 16% while for the oral drug administration was reduced from 38% to 12%.

The Next Step

This system has been shown to be effective in reducing the number of medication administration errors in the general paediatric ward. It should be applied in the normal practice during medication administration in conjunction with other measures as well.

PP-03 Reducing the Number of Medication Administration Errors

in a General Paediatric Ward



-21st

October 2011

24

M. Nazari J, Maskinah A, Haizuna MY, Saruah B, Aishah B, Ismail A, Adinegara. Jasin District Health Office, Malacca State Health Department, Malacca Manipal Medical College, Melaka. Selection of Opportunities for Improvement

Proper usage of Fetal Movement Chart (FMC) among pregnant women above 28 weeks of gestation is important to monitor fetal well-being. The District Perinatal Mortality Review had notified that improper usage of FMC had contributed to high stillbirth rate. The main objectives of the study were to measure the magnitude of proper usage of FMC, identify the contributing factors, implement the remedial measures and evaluate the effectiveness of remedial measures.


The indicator of the study was percentage of proper usage of FMC and the standard set was 90%.


A cross sectional study was conducted on both pregnant women and healthcare staff. Data were collected using interview questionnaire and observational method.


A total of 120 pregnant women and 29 healthcare staffs were randomly selected. Only 74% of pregnant women had properly used the FMC. The contributing factors were FMC not being reviewed by healthcare staffs (p=0.02), unclear explanation (p=0.03), unsatisfactory and inappropriate examples (p=0.01) as well as no reassessment of respondents‟ understanding (p=0.01). Other factors noted were FMC not being self-explanatory (p=0.03) and 7 out of the 29 healthcare staffs were unaware of the existence of the FMC checklist.

Strategy for Change

Staff were re-trained on how to advise mothers on proper use of FMC. The FMC check-list was re-modified. A “Must-see Sticker” was introduced to ensure that staff review the FMC at every visit.

Effect of Change

After three months of remedial actions, the proper usage of FMC increased to 98.3%, the percentage of FMC reviewed by staff increased to 95.0%, explanation understood to 95.0% and appropriate example given to 93.3%. Reassessment of pregnant women‟s understanding of FMC increased to 89.2%.

The Next Step

Continual staff re-training on how to explain and review the FMC by pregnant women at every visit are important to ensure the proper usage of FMC.

PP-04 Improving Proper Usage of Fetal Movement Chart among

Pregnant Women



-21st

October 2011

25

Ruzita J, Dandaithapani T, Muslim AR, Rasidi D, Rozali I, Basiah A, Afidayati A. Department of Psychiatry, Tuanku Fauziah Hospital, Kangar, Perlis.


Readmission is commonly used as an outcome and quality indicator for inpatient services. Schizophrenia was found to be the most commonly diagnosed mental illness among those readmitted into the psychiatric ward. The aims of this study were to reduce the frequency of readmission of patients with schizophrenia after last discharge from the psychiatric ward, Tuanku Fauziah Hospital (HTF) and to look for factors that may contribute to this problem.


We decided to set the standard of rate of readmission of patients with schizophrenia within 6 months of last discharge to less than 25% in keeping with our national indicator for psychiatry.


All the psychiatric cases that were admitted into the psychiatric ward from 2008-2009 were identified and their case notes were traced and reviewed. Eighty patients with schizophrenia admitted to the psychiatric ward from January-June 2010 that fulfilled the inclusion criteria were interviewed using a guided questionnaire.


There were 390 psychiatric cases admitted into the psychiatric ward in 2008 and 386 cases in 2009. Of these, 246 cases (63.08%) were schizophrenia cases in 2008 and 277 (71.80%) in 2009. Of the 246 schizophrenia cases admitted in 2008, 93 (37.80%) of them were readmitted within 6 months of previous discharge. Of the 277 schizophrenia cases admitted in 2009, 97 of them (35.02%) were readmitted within 6 months of previous discharge. The rate of readmission of the schizophrenia patients from 2008 to 2009 ranged from 10.02% to 12.80% higher than the standard.

Strategy for Change

In this study, medication non-adherence and multiple social problems were the most important factors related to frequency of readmission. Psychoeducation was given to improve their knowledge and reduce treatment non-adherence. Home visit services were strengthened to ensure the continuity of treatment and to empower support from the caregivers.

Effects of Change

There was a reduction in the rate of readmission of schizophrenia patients after last discharge from 35.02% to 25.61% post intervention. Providing psychoeducation and psychosocial care reduced the readmission rates among schizophrenia patients.

The Next Step

More studies are needed in this field as it will help in the provision of care in our mental health patients particularly schizophrenia and also those caring for them.

PP-05 Reducing Frequency of Readmission of Patients with Schizophrenia after Last Discharge



-21st

October 2011

26

Norbaizora M, Ruzita MY, Sapinah MK, Kalsom M, Rohani H, W. Mohd Faizal A, Ahmad Syahir S, Norhasriza Z, Nor Syarahani J. Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan.

Pemilihan Peluang untuk Penambaikan

Hospital Universiti Sains Malaysia (HUSM) merupakan Hospital Rakan Bayi, namun bilangan jururawat yang melakukan aktiviti penyusuan ketika di tempat kerja masih rendah (26.7%). Antara penyebabnya ialah pakaian seragam jururawat sedia ada labuh dan sukar disingsing. Ini menyukarkan untuk memerah/memberi susu kepada bayi serta mendedahkan anggota badan yang tidak terlibat semasa aktiviti penyusuan. Projek ini dilakukan untuk mempermudahkan aktiviti penyusuan di kalangan Jururawat di HUSM dengan menjadikan Jururawat sebagai Role Model.


Sasaran projek untuk menurunkan tahap keparahan atau tahap kesukaran melakukan aktiviti penyusuan dari 100% kepada 50% di kalangan jururawat yang mempunyai anak yang berusia kurang dari 2 tahun.


Kaedah pengumpulan data menggunakan borang soal selidik yang diedarkan kepada 60 orang jururawat yang mempunyai anak berusia kurang dari 2 tahun dan masih menyusu untuk mengetahui masalah yang mereka hadapi semasa aktiviti penyusuan di tempat kerja. Soalselidik pemilihan 4 rekabentuk pakaian seragam juga diedarkan kepada 30 orang jururawat di zon penyusuan iatu pakaian seragam berbutang tengah, pakaian seragam berbutang serong, pakaian seragam berzip 6 inci yang diletak 2 sm dari puting ke bawah.


Analisis pemilihan rekabentuk didapati undian tertinggi (76.6%) adalah pakaian seragam berzip 6 inci yang diletak 2 sm dari puting ke bawah.


Penambahbaikan pakaian seragam sedia ada dibuat dengan cara menambahkan zip sepanjang 6 inci pada bahagian kiri dan kanan hadapan pakaian seragam, zip ini diletakkan 2 sm dari atas puting ke bawah.


Projek kami telah berjaya menurunkan tahap keparahan sebanyak 62%. Perbandingan dilakukan sebelum dan selepas penambahbaikan pakaian seragam menggunakan borang soalselidik yang diedarkan kepada responden yang diujicuba. Hasilnya mendapati penjimatan dari segi masa dan kos serta keselesaan ketika aktiviti penyusuan.

Langkah Seterusnya

Antara faktor yang menghalang jururawat melakukan aktiviti penyusuan di tempat kerja adalah rekabentuk pakaian seragam yang sedia ada. Pengubahsuaian yang dilakukan memudahkan semua jururawat menyusukan bayi dengan susu dada. Projek ini tidak terhad kepada jururawat sahaja tetapi akan digunapakai oleh Pembantu Kesihatan HUSM.

PP-06 Meningkatkan Aktiviti Penyusuan di Kalangan Jururawat di Tempat Kerja



-21st

October 2011

27

Arbaiah O, Marina MS, Zaleha J, Zainal AR, Hariyaton R. Batu Pahat Health Clinic, Johor.


Adolescents, target of tobacco industries, had smoking prevalence of 14.7%. Young smokers are future statistics of strokes, heart diseases and cancers. Factors contributing to the poor performance of Quit Smoking Clinic (QSC) among adolescents need to be identified.


To increase percentage of quit smoking among adolescents attending QSC in Batu Pahat to 80%.


Four cross-sectional studies were done between January and March 2009. Secondary data of clinic-based QSC performance were collected and followed by interviews of adolescents identified as failed to quit for year 2008. Providers‟ factors contributing to the quitting were obtained through self administered questionnaires on 26 Medical Assistants (MA) who run the clinic- based QSC. Adolescents from nine selected schools answered the questionnaires distributed.


Data from 2008 showed that only 2(16.7%) of 12 adolescents quit smoking. Of 10 adolescents who failed to quit, 7(70%) had high Fagerstrom score, 9(90%) did not have time and transport convenience to attend clinic-based QSC and 7(70%) revealed no intention of quitting. 61.5% of MAs responded that heavy outpatient workload, uninterested clients (65.4%) and insufficient training in running QSC (53.8%) were factors contributing to low performance of QSC. There were 204(16.5%) smokers from a total of 1231 students who answered the questionnaire. Transport and time inconvenience of the adolescents combined with high workload of MAs prompted the team to look for alternatives for QSC.

Strategy for Change

Smokers enrolled were introduced to the newly developed school-based module, conducted by trained teachers and monitored by trained staff nurses. It was a 1-2 hour session per week for 8 consecutive weeks within the school hours. Factors contributing to smoking and quitting were compared pre and post intervention.

Effects of Change

125(61.3%) of 204 students successfully quit smoking compared to 16.7% quit rate in 2008. Quit smoking activities within school compound and hours resulted in higher success rate.

The Next Step

School-based quit smoking clinics were extended to 21 schools. Continuous improvement of the module and approach is planned with the education department.

PP-07 Increasing the Success Rate of Quit Smoking Clinic among Adolescents



-21st

October 2011

28

Norhana Y, Fatimah M, Mazlinah M, Kamilah M, Che Azizah A. Klinik Kesihatan Negeri Terengganu. Pemilihan Peluang untuk Penambaikan

Pengesanan komplikasi Diabetes Mellitus (DM) yang lengkap di klinik kesihatan perlu dilakukan di peringkat awal bagi mengurangkan kadar morbiditi dan mortaliti. Hasil kajian verifikasi menunjukkan pengesanan komplikasi diabetes yang lengkap sangat rendah iaitu 2.8%.


Unit Kawalan Penyakit Tidak Berjangkit Jabatan Kesihatan Negeri Terengganu telah menjalankan kajian dengan objektif untuk meningkatkan peratus pengesanan komplikasi diabetes yang lengkap dimana indikator adalah peratus kes menjalani pengesanan komplikasi Diabetes yang lengkap dan standard yang ditetapkan adalah 60%. Pemeriksaan Lengkap bermaksud setiap pesakit menjalani kesemua pemeriksaan seperti kaki, neurologi, sistem vaskular periferi, pemeriksaan mata termasuk fundus serta electrocardiogram dan ujian makmal seperti urine microalbumin/albumin, blood urea serum electrolyte dan creatinine.


Kajian telah dijalankan di dua buah klinik yang terpilih di setiap daerah Negeri Terengganu untuk mengenalpasti faktor penyumbang kepada masalah tersebut. Kajian pengetahuan pengesanan komplikasi diabetes telah dijalankan pada 4 hingga 28 Februari 2007. Borang soalselidik telah digunakan dan melibatkan pesakit dan anggota yang terpilih. Selain dari itu audit peralatan dibuat untuk memastikan peralatan mencukupi. Audit sistem penyeliaan dilakukan untuk memastikan adanya sistem yang teratur dalam pengesanan komplikasi diabetes. Kajian semula setelah intervensi dilakukan pada 15 hingga 25 Februari 2009 dan 12 hingga 22 Disember 2010, menggunakan format yang sama.


Peratus pengetahuan baik bagi pesakit adalah sebanyak 15% manakala bagi anggota adalah 7%. Audit teknikal peralatan menunjukkkan 78.6% peralatan mencukupi. Pengesanan komplikasi diabetes yang lengkap ialah 2.8%.


Kursus pengendalian Klinik Diabetes peringkat negeri termasuk demonstrasi pemeriksaan kaki, Kursus „Fundus Photo Grading’ untuk Pegawai Perubatan dan paramedik telah diadakan. Audit klinikal dan teknikal berkala dilaksanakan untuk memastikan pengesanan komplikasi dibuat secara lengkap dan penyeliaan dilakukan secara berkala.


Kajian semula menunjukkan pengetahuan yang baik bagi pesakit meningkat ke 25.9% manakala bagi anggota meningkat ke 22.6%. Audit teknikal peralatan menunjukkkan 92.9% peralatan mencukupi. Sistem penyeliaan pengurusan diabetes telah diwujudkan. Pengesanan komplikasi diabetes yang lengkap telah meningkat dari 2.8% ke 22.9% pada Februari 2009 dan 27.8% pada Disember 2010.

Langkah Seterusnya Memantapkan sistem penyeliaan dan memberi latihan dan kesedaran secara berterusan kepada anggota kesihatan.

PP-08 Meningkatkan Pengesanan Komplikasi Pesakit Diabetes yang Lengkap di Klinik Kesihatan



-21st

October 2011

29

Tchong FL, Nadiah AR, Noriah Y, Timothy B, Marilyn AA. Department of Pathology, Sarawak General Hospital, Sarawak.


Blood Film Malaria Parasite (BFMP) is a screening test used to differentiate the malaria parasite species. A good quality BFMP slide is important for the correct identification of malaria species; therefore unsatisfactory BFMP slides will be rejected.


This study aimed to reduce the rejection rate of BFMP sample from ETD, SGH to less than 5% by conducting appropriate remedial action.


Retrospective record review of 500 samples was carried out from 1 March 2010 until 30 June 2010 to identify the factors for sample rejection. After the remedial actions were taken, a cross sectional study was done from 1 September 2010 until 31 December 2010. Data were collected from from the Laboratory Information System (LIS) and Notification of Specimen Rejection Record.


The data showed 18% of the sample reviewed was rejected due to multiple factors. Unsatisfactory smear received contributed as the main factor for the most sample rejection due to poor preparation technique of BFMP slides. Regular change of staff and lack of supervision were the perceived factors which contributed to the existence of this problem.

Strategy for Change

Five sessions of hands-on training on proper technique of BFMP slide preparation and Continuous Medical Education (CME) was conducted to ETD, SGH staff of all categories, involved in preparing BFMP slides. Experienced personnel from the Vector Unit, Sarawak State Health Department, were invited to be the trainers. Useful tools such as slide spreader and handy guideline were also given to all participants. A short demonstration on proper BFMP slide preparation to all housemen attached to the laboratory was also provided.

Effects of Change

Post intervention data showed the number of BFMP sample rejected was successfully reduced from 18% to 2% (total 500 samples). Re-evaluation carried out in January to April 2011 showed the rejection rate from ETD,SGH was maintained at less than 5%.

The Next Step

To meet the standard, continuous education on sample preparation shall be given to the staff. The remedial actions will be expanded to other departments in SGH for continuous quality improvement.

PP-09

Reducing Rejection Rate of Blood Film Malaria Parasite Sample Due to Unsatisfactory Smear from Emergency and Trauma Department



-21st

October 2011

30

Tan SC, Chin SK, Khaw ES, Rogayah I, Lim JK. College of Nursing Penang, Taiping, Kuantan & Kuching.


Anatomy and Physiology subjects are the foundations of knowledge and generic skills that will influence students‟ success throughout the three years course. Without Anatomy and Physiology, nurses would not know what to watch for in patients with medications reactions, or how these patients are responding to care. Therefore, if the nurse has a thorough understanding of how the body works, she will be better prepared to give safe and quality patient care. The study aimed to identify effective teaching and learning strategy to increase the passing rate of Anatomy and Physiology among student nurses of Year I Semester II.


The four nursing colleges in the Training Division Ministry of Health had decided to set the standard of increasing the passing rate from 70% to 90%.


Retrospective record review from January 2008 to June 2010 showed an increase in the failure rate. Interventional study was conducted from 1 July to 31 December 2010. Remedial measures were evaluated by monitoring the results of summative examinations.


A total of 350 students took part in this study. The result of Summative Examination in November 2010 showed there is an improvement in the passing rate of the subject, Anatomy and Physiology. 51% of the respondents were satisfied with this methodology because it encouraged group interaction and 52% reported that their workload and difficulty in studying Anatomy and Physiology was reduced.

Strategy for Change We introduced Cooperative Learning and the use of log book to enhance students learning and retention power in studying Anatomy and Physiology.

Effects of Change

Retrospective summative examinations of 2 years (2008 -2010) showed about 70% of the students passed the subject on Anatomy and Physiology. The new teaching methodology was implemented for a period of 2 months (July – August). After the implementation the passing rate had increased by 20%, that is from 70% to 90%.

The Next Step

The use of Cooperative Learning and Computer–aided Learning is effective and will be used continuously when teaching Anatomy and Physiology in all nursing colleges.

PP-10 Improving the Passing Rate of Nursing Students in Anatomy

and Physiology Subjects



-21st

October 2011

31

Norazlina MN, Aida Rahayu AG, Shaebah MJ, Asma I, Noor Azhan A. Pejabat Kesihatan Daerah Kubang Pasu, Kedah.


Anemia di kalangan ibu hamil boleh membawa kepada kejadian post-partum hemorrhage, intrauterine death, dan small gestational age. Walau bagaimanapun, kejadian anemia sederhana didapati semakin meningkat di Daerah Kubang Pasu pada tahun 2008. Kajian ini bertujuan untuk mengurangkan peratus anemia sederhana di kalangan ibu hamil pada usia kandungan 36/52 minggu.


Standard yang ditetapkan adalah 18%.


Kajian verifikasi dilakukan dari Februari hingga Mac 2009 melalui semakan kad antenatal, kajian tahap pengetahuan dan sikap ibu hamil serta anggota kesihatan dilakukan dari Apr hingga Mei 2009 dengan menggunakan borang soal selidik. Begitu juga dengan semakan pengendalian kes di klinik juga telah dilakukan melalui semakan kad antenatal dan audit data dari Clinical Practise Guideline(CPG) dan borang semakan.


Kejadian anemia sederhana di kalangan ibu hamil pada 36/52 minggu pada tahun 2007 dan 2008 adalah 15% dan 23%. Tahap pengetahuan dan sikap ibu mengenai anemia adalah 56%, manakala tahap pengetahuan anggota kesihatan adalah 76%. Kesemua anggota kesihatan tidak pernah menghadiri sebarang CME atau kursus mengenai anemia. Semakan kad antenatal mendapati pengendalian kes yang kurang berkesan di mana ibu hamil lewat diberi rawatan hematinik dan ketiadaan defaulter tracing bagi kes yang tidak hadir ke klinik.


Tindakan penambahbaikan dijalankan dengan mengadakan kaunseling dan ceramah berkumpulan kepada ibu hamil bagi meningkatkan tahap pengetahuan dan komplian terhadap rawatan. Anggota kesihatan diberi latihan dan kursus bagi meningkatkan pengetahuan dan pengendalian kes anaemia. Promosi kesihatan di komuniti diadakan bagi meningkatkan kesedaran umum berkaitan anemia seperti ceramah pemakanan di sekolah menengah, serta ceramah ringkas semasa kursus pra perkahwinan.


Berlaku penurunan peratus anemia sederhana di kalangan ibu hamil iaitu 15.6% untuk tahun 2009 dan 12.5% untuk tahun 2010.

Langkah Seterusnya

Pengetahuan ibu dan pengendalian kes yang berkesan di kalangan anggota kesihatan amat penting untuk mengurangkan kejadian anemia di kalangan ibu hamil.

PP-11 Mengurangkan Peratus Anemia Sederhana di Kalangan Ibu

Hamil Pada Minggu 36



-21st

October 2011

32

Yeoh SL, Tan PY, Suhaila R, Azimah A, Nor Hafiza R. Paediatric Oncology Unit, Paediatric Department, Hospital Pulau Pinang, Penang.


A high rate of catheter related blood stream infection (CR-BSI) in paediatric oncology patients may lead to increased mortality, morbidity, patient dissatisfaction and higher financial cost.


To educate caretaker on central venous line (CVL) care and ensure that staff follow the MOGC. A target to reduce our CR-BSI rate to <10 per 1000 catheter day was set as standard.


A retrospective study was done in January 2010 to determine the CR-BSI rate in ward C3. Questionnaires and checklists were used to identify possible contributing factors. A prospective interventional study was done from July 2010 till January 2011 and effectiveness of remedial measures was evaluated.


Pre-remedial survey showed that our CR-BSI rate was 14.6 per 1000 catheter day in January 2010. The reasons identified for this high rate included insufficient knowledge of staff and caretakers in CVL care and hand hygiene, poor compliances to guideline of CVL flushing and dressing and < 80% of patient with proper skin preparation prior to CVL insertion.

Strategy for Change

Our remedial actions included ensuring that patients were free of skin problems and had bathed prior to CVL insertion, only allowing house officers trained in paediatric oncology to do ward C3 calls, training all new C3 oncology staff in CVL care, checking compliance to guideline of CVL care regularly, ensuring caretakers had adequate knowledge in CVL care and hand hygiene and providing pamphlets on CVL care to all caretakers.

Effects of Change

At the midterm review in November 2010, the compliance to model of good care had improved though not ideal. Incidence of CR-BSI in January 2011 was 9.7 per 1000 catheter day.

The Next Step

These measures can be introduced in paediatric daycare and district hospital that manages paediatric oncology cases to ensure optimal CVL care.

PP-12 Reducing Central Venous Line Related Blood Stream Infections among Paediatric Oncology Patients



-21st

October 2011

33

Giam WL, Azhari Wasi NA, Buang A, Dhillon HK, Mohd Zakaria IE, Lee CE, Jinan Taib JT, Ismail NS, Syed Othman SR, Abdul Wahab AR. Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.


Pharmacy UMMC has PharmCARE services for patients with long term prescriptions where advance preparation of medicines can be requested. Despite the availability of this service, a large number of patients still come to the main outpatient pharmacy (OP) for supplies, resulting in under-utilisation of PharmCARE. With the available resources, PharmCARE should be able to serve 400 patients per day.


Reduction in achievable benefit not achieved (ABNA) of PharmCARE patients per day to more than 30% after improvement, without compromising waiting time and patients‟ satisfaction.


Retrospective analysis of the average number of patients was collected from January to December 2009 as verification. The reasons for under-utilisation of PharmCARE were identified using a questionnaire from 11-22 January 2010 in OP pharmacy.


From the study, PharmCARE was only able to serve 90 patients/day compared to 400 patients/day. Thus the ABNA is 77.5%. A total of 250 questionnaires were returned, with the main reason for under-utilisation as lack of PharmCARE awareness (65.6%). Most patients (66%) were interested in courier service for medicine collection.

Strategy for Change

Promotion to create awareness was initiated and a new service called BY-POST was introduced in May 2010 to further attract patients to use PharmCARE services.

Effects of Change

PharmCARE promotion and implementation of the BY-POST service had succeeded in increasing the average number of patients from 90 to 162 patients/day by September without compromising the waiting time and patients‟ satisfaction. It had resulted in 18% ABNA reduction from 77.5% to 59.5%. Failure to achieve the targeted standard was due to unexpected workload for BY-POST service and increase in medication counseling sessions that limited the process of patients‟ recruitment.

The Next Step

Ensuring the continuity and expansion of PharmCARE for all patients with repeat prescriptions will continue to improve the OP pharmacy service.

PP-13 Optimisation of Pharmcare Service in a Tertiary Hospital



-21st

October 2011

34

Mohd Azri MS, Lim GL, Puziah Y, Mohd Nasir O, Mohammad Faidzol T.

Sultan Abdul Halim Hospital, Sungai Petani, Kedah.


Admission of obstetrics patients through the Patient Assessment Centre (PAC) becomes a major workload to the Obstetrics and gynaecological (O&G) Department, Sultan Abdul Halim Hospital (HSAH). A preliminary study on the magnitude of this issue revealed that only 6% of obstetric patients were admitted to the wards within one hour, another 94% of patients were stranded in PAC for up to more than 2 hours. The aim of this study was to identify the contributing factors that cause long admission time at PAC and to formulate appropriate remedial measures to overcome it.


Our aim was to achieve 75% of patients sent to the Antenatal Ward within one hour.


The data were collected for pre and post remedial period, mainly the time started and time finished at every stage of care at PAC and the time interval between each stage and the stage before it.


During the pre remedial study period, only 8.4% of patients managed to be transferred to the Antenatal ward from PAC within 1 hour. Registration process and lengthy clerking were the two main factors for long admission time.

Strategy for Change

Several strategies had been planned to overcome each problem. Continual meetings and orientation of the staff at PAC were carried out.

Effects of Change

After the first reevaluation period, 67.2% of patients in PAC managed to be transferred to their respective wards within 1 hour. Greater improvement was observed during the 4th re-evaluation period where we achieved 71.6%. The time intervals for all stages were also reduced.

The Next Step

We hope to achieve the target of 75% of patients admitted to the Antenatal Ward from PAC within 1 hour. Although the target has not been achieved, there is promising result from the measures implemented and the next step is to sustain current achievement and formulate new strategies to achieve the target.

PP-14 Improving Admission Time at a Maternity Patient

Assessment Centre



-21st

October 2011

35

Morni AR, Siti FJ, Amran MY, Hasniza J, Irdawaty M. Pejabat Kesihatan Pergigian Daerah Hulu Selangor, Selangor.

Pemilihan Peluang untuk Penambahbaikan Pengambilan x-ray adalah salah satu langkah penting dalam pengendalian penyakit pergigian. Imej x-ray yang terang dan jelas amat penting untuk mendapatkan diagnosis yang tepat. Di Klinik Pergigian daerah Hulu Selangor, pengambilan x-ray yang berulang adalah tinggi iaitu 18.1% pada tahun 2008. Ini telah memberi impak negatif terhadap kualiti perkhidmatan dengan meningkatkan pembaziran bahan dan kos. Ia juga menyebabkan peningkatan pendedahan radiasi kepada pesakit dan menyebabkan pesakit bimbang dan cemas, serta melambatkan diagnosis penyakit dengan mempengaruhi keberkesanan dan ketepatan rawatan. Pengukuran Utama Penambahbaikan Objektif kajian adalah untuk mengurangkan peratus x-ray berulang di Klinik Pergigian daerah Hulu Selangor dari 18.1% kepada < 10% (Objektif Kualiti MS ISO 9001: 2008). Tindakan penambahbaikan diambil untuk mengatasi masaalah ini dengan mengenalpasti faktor penyumbang kepada x-ray perlu diulang. Proses Pengumpulan Maklumat Empat sebab utama x-ray berulang adalah teknik pengambilan dan pemprosesan x-ray yang tidak tepat, kualiti bahan yang kurang memuaskan dan masalah teknikal mesin x-ray. Kajian yang dijalankan adalah kajian irisan lintang. Manakala maklumat diperolehi menggunakan borang daftar pengambilan x-ray, jadual penyemakan bekalan, senarai semak prosedur pengambilan x-ray dan borang kajiselidek. Analisis dan Interpretasi Peratus filem x-ray berulang tahun 2008 adalah 18.1%. Faktor penyumbang utama filem x-ray berulang adalah teknik pengambilan x-ray yang salah dan kurangnya pengetahuan dalam pengambilan dan pemprosesan x-ray oleh Pembantu Pembedahan Pergigian (PPP) yang merangkap juru x-ray. Strategi Penambahbaikan Penggunaan film holder semasa mengambil x-ray. Memberi taklimat dan demonstrasi prosedur pengambilan dan pemprosesan filem x-ray kepada semua PPP. Carta aliran pengambilan x-ray disediakan dalan bahasa Melayu untuk difahami. Manakala senarai semak pengambilan x-ray diperbaiki. Kesan Penambahbaikan Setelah penambahbaikan diambil, peratus x-ray berulang telah berkurang dari 18.1% (2008) ke 5.4% pada tahun 2009 dan terus menurun ke 4.6% pada tahun 2010. Langkah Seterusnya Pemantauan berterusan ke atas senarai semak dan rekod pengambilan x-ray. Mesin x-ray dikalibrasi serta kualiti filem dan larutan x-ray dipantau secara berkala.

PP-15 Mengurangkan Peratus X-Ray Berulang yang Tinggi di

Klinik Pergigian



-21st

October 2011

36

Mike C, Fung Z, Tay LH, Nandi Dewi R, Mariani A. Unit Fisioterapi, Hospital Mesra Bukit Padang, Sabah.

Pemilihan Peluang untuk Penambahbaikan Penurunan kefungsian diramal pada kadar penurunan 5% - 10% untuk setiap dekad hidup setelah usia 30 (Sanders, 1995). Kementerian Kesihatan Malaysia menetapkan warga tua adalah berumur 60 tahun ke atas. Di Hospital ini, terdapat 40 orang pesakit geriatrik yang ditempatkan di dua wad kronik. Terdapat 22 orang pesakit geriatrik berada dalam program Fisioterapi. Statistiks hospital menunjukkan, terdapat peningkatan terhadap pesakit jatuh disebabkan masalah keseimbangan badan (balance) di kalangan pesakit geriatrik. Sehingga Mei 2010 sahaja, telah terdapat 5 kes jatuh berlaku di Hospital Mesra Bukit Padang. Projek ini dijalankan bagi mengenalpasti punca masalah yang menyebabkan kelemahan keseimbangan di kalangan pesakit geriatrik ini, seterusnya mengenalpasti program pemulihan untuk pesakit ini.


Indikator kajian adalah mengurangkan peratusan pesakit yang mempunyai masalah keseimbangan badan (balance) sehingga 60%.


Satu kajian berbentuk deskriptif telah dijalankan pada Mei 2010 dengan sampel kajian seramai 22 orang yang berada dalam program Fisioterapi. Setelah penilaian dijalankan 7 orang pesakit telah dikeluarkan daripada kajian disebabkan masalah seperti tidak memahami arahan dan tidak berupaya untuk berdiri. Kajian dijalankan secara soalselidik, temubual dan penilaian fizikal.


Setelah kajian dilakukan, didapati hanya seorang mempunyai keseimbangan badan yang baik dan 14 orang mempunyai masalah keseimbangan badan. Faktor penyumbang adalah kelemahan otot (93%), kurang koordinasi (67%), kesan teraputik ubat (33%), dan masalah gait (13%).


Langkah penambahbaikan seperti latihan kekuatan otot, koordinasi dan keseimbangan, gait, aktiviti rekriasi dan pendidikan kesihatan telah diimplemintasikan.


Selepas implementasi, pesakit yang mempunyai masalah keseimbangan badan berkurang daripada 93.3% ke 66.6%.

Langkah Seterusnya

Walaupun sasaran 60% tidak tercapai, terdapat peningkatan terhadap pengurangan pesakit geriatrik yang mempunyai masalah keseimbangan badan. Pada masa akan datang, program ini akan diperluaskan kepada pesakit geriatrik yang lain bagi mengelakkan risiko jatuh di kalangan pesakit geriatrik di hospital ini.

PP-16 Mengurangkan Ketidakseimbangan Badan di kalangan

Pesakit Warga Tua di Wad Kronik



-21st

October 2011

37

Siow CC, Menaga K, Noor Shafizah J, Muhd Redhuan N. Specialist Clinic Pharmacy, Melaka Hospital, Melaka.

Selection of Opportunity for Improvement

Filling errors will lead to dispensing errors and cause harm to patients. This study was carried out in the Specialist Clinic Pharmacy, Melaka Hospital in order to minimise the filling errors and keep up the standard of 0% filling error set by the Ministry of Health.


This study analysed the factors which led to filling errors during office hours on five working days. The standard set was 0% filling error.


A prospective study was conducted from 1 June until 31 August 2010 to detect the filling errors and to analyse the contributing factors. A data collection form was distributed to the person involved in the error upon error detection by the pharmacist in charge. Data collected was keyed in and analysed using Microsoft Excel.


By using the data collection forms, the contributing factors were analysed. Human factors which included carelessness, stress and inexperience contributed most (25%) to the filling errors. The study showed that trainees contributed to the most errors (89%) compared to pharmacists‟ assistants (9%) and pharmacists (2%). 78% of errors were detected during peak hours.

Strategy for Change

The remedial measures included 5s implementation, increased number of staff (during office hour, peak hour and lunch calls) and supervision of new staff. Next, three persons per week were assigned to manage the telephone calls (disturbances at work place).

Effect of Change

Filling errors were reduced from 0.93% to 0.58%. Human factor was chosen to be the main contributing factor.

The Next Step

The study and the remedial measures proved to be effective, thus the effort will be continued until 0% medication error had been achieved.

PP-17 Minimising the Filling Errors in a Specialist Clinic Pharmacy



-21st

October 2011

38

Shubhashini Y, Poh EP, Gong VHM, Kogilavaani J, Kasturi R, Che Sam AK, Normadiniatul SMH, Nur Fazlina MN. Department of Ophthalmology & Medical Social Unit,Hospital Raja Permaisuri Bainun (HRPB), Ipoh, Perak.


Cataract surgery wait-time has important clinical, public health and health policy considerations. Delay in cataract surgery reduces patient‟s quality of life (QOL), increases risk of lens-related complication and is associated with poorer outcome. There was a mean cataract surgery wait-time of 23 weeks for patients with mature cataracts in the Department of Ophthalmology, HRPB, Ipoh.


This QA project identified the contributing factors and introduced remedial measures to reduce the cataract surgery wait-time for patients with mature cataracts to 8 weeks.


A cross-sectional study was conducted from January to March 2009 followed by a prospective study from January to March 2010 to evaluate the effectiveness of remedial measures.


The rate of surgery within 8 weeks was 26.7%. The mean time for approval of intraocular lens (IOL) was 3 months. The contributing factors were no proper prioritisation of cataract surgery wait-list, high postponement rate, financial constraints, defaulters and lack of awareness on the need for second eye surgery.

Strategy for Change

Remedial measures taken were prioritising wait-list for patients with mature cataract to a maximum wait-time of 8 weeks. All patients with uncontrolled medical or ocular conditions were admitted to be stabilised and operated. A special medical social unit referral for IOL with approval within 4 weeks was established. Patients with second eye mature cataract were listed directly for surgery within 8 weeks postoperatively.

Effects of Change

There was a significant shortening of the cataract surgery wait-time for patients with mature cataract from 23 weeks to 8 weeks from January to March 2010. The ABNA was overcome. The remedial measures were successful in prioritising cataract surgery wait-list.

The Next Step

Continuous implementation of remedial measures will ensure improvement in the quality of our cataract surgery service.

PP-18 Re-Engineering the Cataract Surgery Wait-Time Strategy



-21st

October 2011

39

Nurul Atikah H, Mohd Zahidi H, Kartini M, Sahaimi M, Nik Abdul Aziz RS. Hospital Pasir Mas, Kelantan.


Peningkatan peratusan penolakan kes pembedahan yang dijadualkan didapati semakin meningkat daripada 2.5% pada tahun 2007 kepada 13% pada tahun 2009. Walaupun mengikut Standard National Indicator Approach (NIA) Kementerian Kesihatan, Malaysia jumlah penolakan kes pembedahan tidak boleh melebihi 15%, terdapat peningkatan peratusan yang berlaku. Ini membimbangkan pihak Dewan Bedah di samping mendatangkan implikasi kepada jabatan, anggota dan pesakit.


Kajian ini bertujuan untuk menurunkan peratusan penolakan kes pembedahan yang dijadualkan dilakukan di Dewan Bedah Hospital Pasir Mas. Standard yang ditetapkan adalah kurang daripada 5%.


Kajian ke atas rekod sebab kes pembedahan dibatalkan dibuat pada 16 hingga 31 Disember 2010, kaji selidik tahap pemahaman anggota wad mengenai pemantauan pesakit dibuat pada 22 Disember 2009 hingga 18 Januari 2010 dan kajian tahap pengetahuan pesakit telah dilakukan pada 29 hingga 31 Disember 2009 dengan menggunakan kaedah borang soal selidik.

Analisis Dan Interpretasi

Analisis terhadap 48 kes pembedahan yang ditolak menunjukkan 54% merokok, 10% tidak berpuasa, 21% masalah teknikal dan 15% kegagalan kakitangan memenuhi kehendak senarai semak pembedahan. Tahap pemahaman kakitangan mengenai senarai semak 68% dan didapati 88% anggota memberi penekanan kepada pesakit mengenai kepentingan mengikut arahan premeditasi. Hasil kajian pesakit pula mendapati 84% memahami dan 62% mempunyai maklumat persediaan sebelum pembedahan.


Langkah penambahbaikan telah diambil dengan mengemaskini penggunaan senarai semak pra pembedahan, mengadakan taklimat dan kursus kepada anggota, meletakkan papan tanda amaran „MEROKOK BOLEH MEMBATALKAN PEMBEDAHAN‟ di setiap katil pesakit terlibat dan menyediakan pamplet arahan serta nasihat yang perlu diikuti oleh pesakit sebelum menjalani pembedahan.


Peratusan penolakan kes pembedahan berjaya diturunkan daripada 13% pada tahun 2009 kepada 4.8% dari Januari hingga Ogos 2010. Selepas penambahbaikan berterusan dilakukan, peratusan penolakan September 2010 hingga Mac 2011 menunjukkan penurunan kepada 2.9%.

Langkah Seterusnya

Langkah proaktif serta komitmen anggota menggunakan langkah pemulihan merupakan faktor utama kejayaan kajian. Penambahbaikan dan penyemakan semula akan dijalankan apabila kelemahan dikesan bagi meningkatkan perkhidmatan di Dewan Bedah Hospital Pasir Mas.

PP-19 Menurunkan Peratusan Penolakan Kes Pembedahan Dewan Bedah



-21st

October 2011

40

Molen A, Myat SY, Lily D, Chanic B, Landsee DM, Juliana DJ, Abby B. Department of Obstetrics and Gynaecology, Bintulu Hospital, Sarawak.


Hospital Bintulu is the referral centre where maternal problems are anticipated. Data showed that mothers experiencing third degree tear had not attended antenatal education/clinic. The study aim was to identify the risk factors and implement measures to reduce the incidences.


The team had decided to set the standard of not more than 1% incidence of third degree tear among total number of vaginal deliveries per year.


Record reviewed from January 2007 to December 2009 revealed that there was high incidence of third degree tear among primigravida and non-antenatal cases.

Mothers admitted from January to June 2010 were interviewed to identify weaknesses during antenatal check-up. Nurses conducting deliveries were supervised. Intervention was carried out from July to December 2010. Remedial measures were evaluated by monitoring all high risk mothers.


Among 1515 deliveries from January to June 2010, multiple contributing factors were identified. Data showed that primigravida/nulliparity, mothers with history of big baby/previous tear and non ante-natal mothers were at risk. We realised that preparation and process of delivery were not properly done due to lack of knowledge regarding proper delivery technique.

Strategy for Change

Strategies implemented were coordinating with Maternal and Child Health Clinic staff to impart proper education, close supervision, regular Continuous Nursing Education, appropriate perineum protection, appropriate time for episiotomy and no sweep and stretch.

Effects of Change

The strategies were applied and there was a reduction from 72 (2%) in 2009 to 23 (0.7%) incidences in 2010. During the monitoring period January to June 2011, there was further reduction to 6 (0.4%) incidences. From this study, we learned that ante-natal education and good delivery technique may reduce the incidence of 3rd degree tear. Staff became more committed, knowledgeable and skillful.

The Next Step

The strategies were effective and will be continuously practiced in our daily activities.

PP-20 Reducing the Incidence of Third Degree Tear in Obstetrics & Gynaecology Department



-21st

October 2011

41

Wong MK, Abdullah A, Justin F. Laboratory and Blood Bank Unit, Hospital Labuan, Wilayah Persekutuan Labuan.


Clinicians expect culture and sensitivity (C&S) reports to be ready within 2 days. Past experience had showed that we were far from meeting the targeted turn-around-time (TAT) which is 76%. Delay in producing reports had resulted in prolonged hospitalisation. This study aimed to improve TAT of C&S.


Two key measures for improvement, “Percentage of C&S TAT within Target (TAT%)” and “90th Percentile of C&S TAT (TAT-P90)” were used. TAT% is an overall measure of performance by setting the targeted TAT at the 3rd day. Meanwhile, TAT-P90 measures the process efficiency by showing the longest TAT of 90% of C&S. The aims were to achieve 90% TAT within target and to have TAT-P90 less than 3 days. TAT was defined as the time from receiving samples to despatching reports.


A retrospective-prospective study design was employed starting from November 2010. Data were collected retrospectively for November through LabNet to assess the extent of the problem. Subsequent data were collected prospectively from December. Workflow Analysis was also carried out to disclose inefficiency in the C&S procedure.


Workflow Analysis revealed that precious time was wasted over the weekend when microbiological laboratory was closed. Critical information for treatment e.g. Gram-group and probable bacterial identity already available on the 2nd day of culture was withheld until the final report was prepared.

Strategy for Change

Standardised preliminary C&S results were dispatched to wards since December. Holidays and weekends duty roster were implemented from January onwards. Improving the TAT was also set as Sasaran Kerja Tahunan for the staff.

Effects of Change

TAT% was increased to and maintained at more than 95% from January onwards. At the same time, TAT-P90 was reduced to less than 3 days. This achievement boosted staff morale.

The Next Step

The interventions were shown to be effective and have been implemented since then and TAT% and TAT-P90 have become the Key Performance Indicators for microbiological services.

PP-21 Improving Turn-Around-Time of Culture and Sensitivity

Testing



-21st

October 2011

42

Navin Kumar L, Chin ST, Rachel T, Lim KY, Fudziah A. Pharmacy Department, Kuala Lumpur Hospital, Kuala Lumpur.


Poor glycemic control of patients with Type 2 Diabetes which leads to diabetes related complications and escalating healthcare cost could be contributed by low medication adherence.


Morisky Score (measure of medication adherence) and HbA1c (measure of glycemic control) were selected. Standard of Good Care was defined as Morisky Score of more than 6 and HbA1c reduction of more than 1%.


Patients with Type 2 Diabetes who attended the Physician Clinic were divided into the Interventional and Control Group (known as Standard Care group). HbA1c data and Morisky scores of the two groups were recorded.


Both groups showed low medication adherence [mean Morisky Score of 4.23 (Interventional) and 4.00 (Standard Care)] and poor glycemic control [mean HbA1c of 10.6% (Interventional) and 10.7% (Standard Care)].

Strategy for Change

Change of process was applied by introducing a new service called Medication Therapy Adherence Clinic (MTAC Diabetes) for the Interventional group while the other group continued receiving the existing service. Patients who attended MTAC Diabetes clinic were seen by a pharmacist on a monthly basis and received blood glucose and weight monitoring, medication adherence assessment, drug related problem solutions, medication dispensing, individualised medication counselling and diabetes education besides their doctor‟s follow-up. Both groups were followed up prospectively for a period of 9 months.

Effects of Change

During the post-remedial phase, medication adherence levels of patients in Interventional group improved significantly from a mean Morisky score of 4.23 to 7.84 while their mean HbA1c level showed a significant reduction of 1.7% from 10.6% to 8.9%. The Standard Care group only showed a minimal increase in Morisky Score from 4.00 to 6.14 and HbA1c reduction of 0.6% from 10.7% to 10.1%, although findings were both not significant (p>0.05). A Cost Effectiveness Analysis (CEA) found MTAC Diabetes (Interventional) to be more cost effective (RM 446.01 per 1% HbA1c reduction) compared to Standard Care (RM 1347.73 per 1% HbA1c reduction).

The Next Step

Continuous medication counselling and monitoring of patients with Type 2 Diabetes by the pharmacist had shown positive clinical and economic outcomes. Therefore, this service will be extended to patients with Type 2 Diabetes at the Out-Patient Department.

PP-22 Clinical And Economic Impact of Pharmacist-Run Medication Therapy Adherence Clinic Service on Patients With Type 2 Diabetes



-21st

October 2011

43

Hajar HR, Vijayamanohar K, Wan Aini WY, Nadia DB, Umi A. Bangsar Dental Clinic, Federal Teritory of Kuala Lumpur.


Retention rate of Fissure Sealant (FS) in 2009 within a year of application in Bangsar Dental Clinic was 65%. Intact FS can prevent caries from occurring thus reducing cost and time needed for restoration. Identifying the contributing factors for failure of FS application will enable us to implement necessary corrective measures.


By strictly adhering to Standard Operating Procedure (SOP) and Model of Good Care a (MOGC) 100% retention rate of FS within a year done by our Staff Nurses (SNs) was targeted.


A cross sectional study was conducted in five schools from September 2010 to January 2011. 81 students and nine SNs from Bangsar Dental Clinic were involved. Data were collected using FS Check list and Review Form. All SNs were observed on how they carried out the FS procedure.


This study revealed that poor tooth selection such as the molars were partially erupted, frank caries and decalcified enamel (46.67%) contributed to poor retention of FS. Poor moisture control was another factor, as the SNs did not isolate the tooth properly, did not use saliva ejector and continued the procedure even after the surface was contaminated with saliva (40%). Lack of vaculysers resulting in some SNs doing the procedure without a vaculyser was also a factor.

Strategy for Change

Talks, hands-on demonstration and one-to-one training were carried out to ensure all the SNs understood the implementation of the procedure. Emphasis was given on the use of vaculysers during the procedure.

Effects of Change

After remedial action was taken, the retention rate increased from 65% to 95.3% and only 4.7% FS was partially lost.

The Next Step

To continue FS assessment in this clinic and to re-train all newly posted SNs in Bangsar Dental Clinic on how to carry out this procedure by following SOP.

PP-23 Increasing Retention Rate of Fissure Sealant among Primary School Children



-21st

October 2011

44

Mohd Fozi K, Junaidah I, Azirah Y, Nurul Azlyn MY, Mahani K, Ali O, Mardiana A, Hamiza H. Kangar Health District Office, Perlis.


Management of asthma must be based on level of control therefore monitoring of asthma control is very important in ensuring optimum treatment. Audit on Appropriate Management of Asthma 2009 showed that only 22.1% of asthma patients in Kangar District were monitored for level of control. A standard tool to assess level of control is using Global Iniatiative for Asthma (GINA) Guideline 2009.


Indicator used is percentage of asthma patients monitored for level of control using GINA Guideline at health clinics in Kangar District. Our objective was to increase percentage of asthma patients monitored for level of control using GINA Guideline at Health Clinics in Kangar District from 22.1% to 50%.


Magnitude of poor monitoring of asthma control was measured by auditing 270 patients cards in 9 Health Clinics selected by systematic random sampling. Auditing of Asthma Clinic Management System using Audit Checklist and evaluation of knowledge among patients and staffs using questionnaire were done to identify the possible causes of problem. Analysis and Interpretation Only 17% of patients were monitored for level of control using GINA Guideline at health clinics in Kangar District. Monitoring process for level of control did not follow standard in MOGC. 79.5% of health clinics staff had unsatisfactory and poor knowledge on asthma. Only 50% of asthmatic patients had good knowledge on asthma. Possible contributing factors to the problem are untrained personnel, lack of health education to patients and poor monitoring system at health clinics.

Strategy for Change New strategies instituted to improve patients monitoring system at clinics were introducing GINA classification checklist, improvisation of patients‟ cards and setting standard appointment system. Regular health education to patients and staffs were organised to improve their knowledge. Effects of Change Percentage of asthma patients monitored for level of control using GINA Guideline at health clinics in Kangar District had increased from 17% to 58.7%. Adherence to MOGC, level of staff and patients knowledge had also increased. The Next Step To maintain and further improve the standards that had been established and achieved.

PP-24 Increasing Percentage of Asthma Control Monitoring at District Health Clinics



-21st

October 2011

45

Samurah AR, Ganespathy P, Ibrahim AF, Molina J. Kampung Pandan Health Clinic, Wilayah Persekutuan Kuala Lumpur.


Identifying patients with diabetic foot problems is important to ensure they are targeted for appropriate

management to prevent further foot complications. Detection of diabetic foot problems at Wilayah Persekutuan

Kuala Lumpur State Health Department (JKWPKL) had been poor whereby the Audit Diabetic Control Management

(ADCM ) 2009 revealed that the detection rate was 3%. Detection rate at Kampung Pandan Health Centre was only

6.5%. Based on literature review the pick-up rate should be 70-80%. This study aimed to increase detection rate of

diabetic foot problems among patients with diabetes at Kampung Pandan Health Clinic.

Key Measure for Improvement

We set a standard of40% detection rate of diabetic foot problems among patients with diabetes.


Patients with diabetes were given appointment dates for foot care assessments. Fifteen patients per session were

allocated on Monday and Friday mornings. Fifteen staff were involved in the study including 6 staff nurses and 9

community nurses. Continuous Medical Education (CME) on foot assessment was done for all the nurses prior to the

study.


A total of 484 patients with diabetes were assessed from October 2010 until April 2011.Of these, the detection of

diabetic foot problems increased only to 24%. Each staff was re-assessed by a Family Medicine Specialist. Staff

knowledge was average and their examination skills were still poor. Only half of the staff were able to make

correct diagnosis. Each card was audited and the documentation was also noted to be poor.

Strategy for Change

All the staff were retrained through dedicated personalised skill training by a Family Medicine Specialist on proper

examination techniques, on how to make correct diagnosis, on their knowledge and proper documentation.

Effect of Change

Post remedial action revealed marked improvement on technique of examination, ability to make correct diagnosis

and staff knowledge. A different group of 261 patients assessed between 20 May to 18 August 2011 revealed a

marked increase in detection rate of diabetic foot problems to 72%.

The Next Step

The foot care assessment protocol had been implemented as a routine annual foot care assessment at Kampung

Pandan Health Clinic. The format of the clinical monitoring protocol can also be applied to improve detection of

other diabetic complications. These strategies will be shared with other clinics in JKWPKL in order to improve the

rate of detection of diabetic foot problems.

PP-25 Improving Detection Rate of Diabetic Foot Problems Among Patients with Diabetes



-21st

October 2011

46

Norazema AA, Samsir Asuwat S, Mohd Zulfadhli MS, Mohd Zahari Y, Md Kamal Ariffin AG, Zainal Abidin I, Azmi A, Jamaliah J. Pejabat Kesihatan Daerah Sabak Bernam dan Pejabat Kesihatan Daerah Kuala Selangor, Selangor.

Pemilihan Peluang untuk Penambahbaikan Semua kantin sekolah menengah di kedua-dua daerah dikehendaki menjalani pemeriksaan kebersihan. Walaubagaimanapun peratus premis bersih kantin sekolah menengah yang mendapat markah rating kurang dari 70% di kedua-dua daerah masih rendah dimana pada tahun 2006 jumlah peratus premis bersih adalah 20% dan tahun 2007 14%. Markah rating merupakan jumlah demerit yang ditolak dari jumlah keseluruhan 100% sekiranya adanya kesalahan dilakukan.


Pejabat Kesihatan Daerah Sabak Bernam dan Pejabat Kesihatan Daerah Kuala Selangor telah menetapkan standard 100% premis kantin sekolah menengah bersih di daerah Kuala Selangor dan Sabak Bernam.


Kajian verifikasi dijalankan dari Mei hingga Ogos 2008, Kajian Pertama Pre-intervensi dijalankan dari September hingga November 2008 dan Kajian Kedua Pos-intervensi dijalankan dari Januari hingga Oktober 2009. Data diperolehi melalui borang senarai semak, soal selidik isi sendiri, borang pemeriksaan KMM 3P2 dan rekod pemeriksaan kantin sekolah menengah.


Data dibahagikan kepada 4 bahagian iaitu Perancangan Pemeriksaan Premis, Pemeriksaan Premis, Pemeriksaan Kesihatan dan Penilaian Tahap Pengetahuan Pengendali Makanan. Kajian verifikasi menunjukkan peratus Pemeriksaan Premis sebanyak 94.2%, pemeriksaan kesihatan sebanyak 48% dan tahap pengetahuan pengendali makanan sebanyak 26%. Faktor utama premis bersih kantin tidak dapat dicapai adalah pengendali makanan.


Penambahbaikan yang dilaksanakan ialah mewujudkan jadual pemeriksaan kantin sekolah menengah, perbincangan bersama pengendali dan pengusaha makanan, mengadakan program pendidikan kesihatan, mewujudkan notis amaran bertulis dan penguatkuasaan Prosedur Penutupan Premis di bawah Akta Makanan 1983.


Kajian Pos-intervensi menunjukkan peningkatan sebanyak 100% untuk pemeriksaan premis, 86% untuk pemeriksan kesihatan dan 83% untuk tahap pengetahuan pengendali makanan.

Langkah Seterusnya

Langkah penambahbaikan menunjukkan keberkesanan dan dipraktikkan bersama program yang telah rancangkan.

PP-26 Meningkatkan Peratus “Premis Bersih” Kantin Sekolah Menengah



-21st

October 2011

47

M. Adam MA, Nini Shuhaida MH, Rohanita N, Badariah S, Badariah M, Wan Hafizah WM. Pejabat Kesihatan Daerah Kuala Terengganu, Terengganu.

Peluang Untuk Penambahbaikan

Anemia semasa hamil adalah masalah perubatan yang perlu dielakkan untuk mengurangkan risiko morbiditi dan mortaliti kepada ibu dan bayi. Kejadian anemia sederhana di daerah Kuala Terengganu didapati melebihi 20% setiap tahun. Kajian ini dilakukan untuk mengenalpasti punca masalah dan cara mengatasinya untuk menurunkan kejadian anemia sederhana di kalangan ibu hamil.


Pejabat Kesihatan Daerah Kuala Terengganu telah menetapkan untuk mengurangkan kejadian anemia sederhana ibu hamil pada 36 minggu kehamilan kepada kurang 20%.


Semakan reten KIB 210A dijalankan untuk verifikasi data. Audit kad antenatal secara retrospektif dijalankan bagi mengenalpasti faktor risiko anemia. Kajian hirisan lintang mengenai pengetahuan berkaitan anemia dibuat menggunakan borang soal selidik untuk ibu dan jururawat.

AAnnaalliissiiss ddaann IInntteerrpprreettaassii

Kejadian anemia sederhana adalah sehingga 29.7%. Faktor risiko yang dikenalpasti ialah grandmultipara (58.6%),

jarak kelahiran kurang dua tahun (58.6%), lewat kesan anemia (64%), lewat booking (57.5%), rawatan tidak

mengikut protokol (64.7%), kurang penyeliaan (55.6%) dan tidak mengambil makanan kaya zat besi (71.6%). Ibu

hamil didapati tidak faham tentang bahaya anemia kepadanya dan bayi (35%), kepentingan pengambilan hematinik

(27%) dan masa sesuai mengambil hematinik (60%). Terdapat jururawat tidak tahu definisi (30%), klasifikasi (51%),

bagaimana anemia berlaku (45%) dan tanda-tanda anemia (29%).


Pelaksanaan kursus dan taklimat penggunaan garis panduan dan protokol kepada anggota kesihatan, audit kejururawatan, mewujudkan personalised care, menggunakan flip-chart untuk pendidikan kesihatan, membuat demo masakan menu kaya zat besi, pemantauan pengambilan hematinik secara berkala dan memperkasakan amalan perancang keluarga.


Kejadian anemia sederhana didapati menurun sehingga 16.4%. Intervensi yang dilakukan memberi impak positif. Jururawat lebih mahir mengendalikan kes anemia dan kesedaran ibu tentang anemia meningkat. Pengetahuan mengenai anemia dan disiplin untuk mematuhi garis panduan adalah sangat penting untuk memastikan kejadian anemia tidak meningkat melebihi sasaran.

Langkah Seterusnya

Intervensi ini berkesan untuk menurunkan kejadian anemia sederhana dan perlu diteruskan dalam amalan harian dengan penilaian berkala.

PP-27 Menurunkan Kejadian Anemia Sederhana di Kalangan Ibu

Hamil



-21st

October 2011

48

Nik Azi Azuha NH, Norhayati A, Norizah M, Saluwani AH, Nuraini M. Obstetrics and Gynaecology Department, Raja Perempuan Zainab II Hospital , Kota Bharu, Kelantan.


Patients planned for induction of labour (IOL) with intravenous (IV) Oxytocin have to wait for a long time before induction is started, hence delaying labour initiation. This subsequently can give rise to poor maternal and perinatal outcomes and may cause distress to patients and relatives. A retrospective study revealed that the majority of cases were delayed and initiated after 12.00 noon. This study aimed to identify the contributing factors for and to reduce the delay in induction of labour.


The team set a standard of 80% cases for IOL to be started before 12.00 noon in anticipation of adverse or poor maternal and perinatal outcomes. Should these occur, then it is preferable to be in the daytime.


A verification analysis was done from November to December 2009 to identify the factors for the delay in IV oxytocin initiation. A cross-sectional study was carried out from January to May 2010. Remedial measures were implemented and the results analysed.


A total of 50 cases were evaluated for this study. Every step of the process of care was studied. Before remedial measures were implemented, only 35% of patients had IV Oxytocin initiated before 12.00 noon. The delay between the decision for induction and the initiation of IV Pitocin in the labour room was mainly associated with the absence of a systematic approach in guiding the caretakers in dealing with cases for IOL.

Strategy for Change

Induction has to be carried out as early as possible in order to anticipate any adverse outcomes related to the procedure. We had developed a strategy towards managing patients for IOL by introducing induction beds/rooms, induction sheet, induction board, and organising Continuous Medical Education for the staff.

Effects of Change

Implementation of remedial measures had resulted in dramatic improvement in every step of the induction process, whereby 77% of patients were initiated on IV Oxytocin before 12.00 noon, compared to 35% previously. We had a better outcome of delivery and a more satisfactory perinatal outcome by the reduction in the number of emergency caeserian section.

The Next Step

This new strategy of change is effective and will be applied continuously in our daily practice with regular re-assessment.

PP-28 Delay In Induction of Labour with Oxytocin



-21st

October 2011

49

Norhasmani M, Abby Ang SY, Rashidah AR, Omar O, Norfajariah I, Arzarizah A. Farmasi Pesakit Luar Hospital Raub, Pahang.


Pertukaran rupa ubat sering terjadi di agensi kesihatan Kementerian Kesihatan Malaysia dan ia sesuatu yang tidak

dapat dielakkan. Jika masalah ini tidak ditangani, ianya boleh membawa kepada kesilapan dalam pengambilan

ubat-ubatan dan seterusnya mengakibatkan komplikasi penyakit. Oleh yang demikian, adalah penting unit farmasi

mengambil inisiatif dalam meningkatkan pengetahuan pesakit tentang perubahan rupa ubat.


Objektif kajian ini ialah untuk meningkatkan pengetahuan pesakit tentang perubahan rupa ubat di Farmasi Pesakit

Luar Hospital Raub. Projek QA ini diharap dapat menangani masalah kekeliruan ubat ini dengan berkesan.


Kajian dengan menggunakan borang soal selidik telah dijalankan di Farmasi Pesakit Luar bagi mengukur peratusan

pesakit yang tahu tentang pertukaran rupa ubat dan bagi mengenalpasti faktor penyumbang. Bagi kajian pra-

intervensi, data telah diambil bermula Disember 2009 sehingga Januari 2010 manakala kajian selepas intervensi di

jalankan bermula Mei sehingga Jun 2010.


Hasil kajian mendapati hanya 42% pesakit tahu tentang perubahan rupa ubat yang diambil. Faktor penyumbang

utama kurang pengetahuan adalah kurang penyebaran informasi, kekerapan pertukaran ubat dan masalah bahasa

serta jumlah ubat yang diambil.


Kumpulan QA kami telah menjalankan penambahbaikan untuk meningkatkan pengetahuan pesakit tentang

perubahan rupa ubat di Farmasi Pesakit Luar. Langkah penambahbaikan yang telah diambil adalah seperti

membuat inovasi dengan menghasilkan “SMART BOARD” yang dipamerkan di setiap kaunter pembekalan ubat,

penyediaan fail rujukan untuk menyimpan semua ubat yang bertukar rupa serta membuat perubahan dalam

cartalir proses kerja pembekalan ubat.


Setelah penambahbaikan dijalankan selama 2 bulan, didapati pengetahuan pesakit telah meningkat daripada 42%

kepada 74%.

Langkah Seterusnya

Penambaikan tersebut diharap akan dapat meningkatkan pengetahuan pesakit tentang perubahan rupa ubat supaya

pesakit mendapat rawatan yang lebih selamat dan berkualiti daripada ubat yang diambil, sejajar dengan Dasar

Ubat Nasional. Limitasi kajian ini adalah ia hanya melibatkan pesakit di jabatan pesakit luar dan adalah diharapkan

kajian ini dapat diteruskan dan digunapakai di semua unit farmasi.

PP-29 Meningkatkan Pengetahuan Pesakit Tentang Perubahan

Rupa Ubat di Farmasi Pesakit Luar



-21st

October 2011

50

Anna T, Masni L, Lena C, Chua YL, Jeanyfer L, Mohd FA, Lucina L. Hospital Tenom, Sabah.


Lower Segment Caesarian Section (LSCS) merupakan pembedahan yang dilakukan terhadap ibu yang mempunyai masalah melahirkan anak. Oleh kerana jangkitan boleh berlaku, maka proses persediaan dan perlaksanaannya perlulah mengikut prosedur yang telah ditetapkan. Kajian ini dilakukan bagi melihat keberkesanan langkah yang telah diambil bagi mengurangkan kejadian LSCS wound breakdown di Hospital Tenom.


Memastikan insiden LSCS Wound Breakdown kurang dari 15% dalam tempoh kajian selama 6 bulan.


Kajian berbentuk irisan lintang dijalankan dari bulan Julai - Disember 2010. Subjek utama adalah semua ibu yang menjalani pembedahan LSCS. Data diperolehi melalui borang soal selidik dan senarai semak yang diisi oleh Pegawai Perubatan, anggota Wad Materniti, Unit Dewan Bedah, Klinik Kesihatan Ibu dan Anak dan semua Klinik Desa di Daerah Tenom.


Kadar LSCS wound breakdown meningkat dari 40.60% (Julai-Disember 2009) kepada 43.75% (Januari-Jun 2010). Punca masalah ini adalah tahap pendidikan yang rendah, amalan pantang larang serta adat resam yang tidak seiring dengan perubatan moden. Anggota kesihatan yang kurang pengalaman dalam perkhidmatan, pendidikan kesihatan yang tidak seragam dan masalah kualiti udara Dewan Bedah juga menjadi punca insiden ini berlaku.


Perhatian diberikan kepada memantapkan perlaksanaan pendidikan kepada anggota kesihatan seterusnya kepada ibu, agar mereka memahami cara penjagaan luka LSCS di rumah. Kaedah pemantauan luka LSCS juga diperkemaskan dengan mewujudkan senarai semak dan melakukan lawatan rumah oleh anggota kesihatan. Dewan Bedah juga ditutup sementara bagi kerja pembersihan dan penyelenggaran.


Insiden LSCS wound breakdown Hospital Tenom berjaya dikurangkan dari 43.75% kepada 13.64%.

Langkah Seterusnya

Amalan, pengetahuan dan kerjasama antara anggota kesihatan serta fasiliti yang lengkap adalah penting bagi memastikan perkhidmatan yang selamat dan berkualiti. Kaedah pemantauan yang berkesan juga diperlukan bagi memudahkan urusan mengesan masalah serta mengukur prestasi penambahbaikan yang telah dilakukan.

PP-30 Mengurangkan Kadar Kejadian LSCS Wound Breakdown



-21st

October 2011

51

Norasikin M, Rubiah L, Masriah M, Zaitun I, Masliza M, Roslenda M. Pejabat Kesihatan Pontian, Johor.


Kajian WHO menunjukkan kehidupan yang tidak aktif secara fizikal menyumbang kepada 1.9 juta kematian di seluruh dunia. National Health Morbidity Survey (2006) menunjukkan 43.7% penduduk Malaysia tidak aktif secara fizikal dan bilangan penduduk di negeri Johor tidak aktif secara fizikal berjumlah 46.0%. Kajian di kalangan kakitangan awam Daerah Pontian mendapati hanya 19.4% bersenam setiap hari dan 18.4% bersenam 3 kali seminggu.


Meningkatkan peratus responden yang mengamalkan aktiviti fizikal. Standard yang ditetapkan adalah melebihi 70 peratus (>70%).


Satu kajian irisan lintang telah dijalankan pada bulan Jun 2008 ke atas 151 orang penduduk Kampung Permatang Duku, Benut, Pontian berumur 10 tahun ke atas. Kajian menggunakan borang soalselidik serta pemeriksaan fizikal dan makmal.


Kajian menunjukkan hanya 52.30% daripada responden mengamalkan aktiviti fizikal. Hasil kajian mendapati pengetahuan yang rendah, sikap negatif, amalan yang negatif dan tidak komplain terhadap senaman menyumbang secara signifikan (p<0.05)


Memperkenalkan “Kempen Berjalan 10,000 Langkah” setiap hari kepada masyarakat Daerah Pontian. Promosi ”Kempen Berjalan 10,000 Langkah” dengan mempamerkan banting kempen 10,000 langkah dan edaran risalah di kesemua 8 klinik kesihatan, 33 klinik desa dan jabatan kerajaan. Ceramah, promosi melalui radio dan lawatan ke mukim dijalankan di peringkat Daerah Pontian. Penubuhan Ahli Jawatankuasa peringkat daerah dan dijalankan aktiviti berjalan 10,000 langkah secara berterusan di semua peringkat Daerah Pontian juga dijalankan. Kesan Penambahbaikan

Penilaian semula pada bulan Disember 2008 ke atas responden yang sama mendapati 76.3% dari 151 responden mengamalkan aktiviti fizikal selepas kempen 10,000 langkah dijalankan. Aktiviti fizikal telah dapat ditingkatkan dari 52.3% kepada 76.3%. Pengetahuan, sikap positif dan kepatuhan terhadap senaman juga telah dapat dipertingkatkan (melebihi 70%).

Langkah Seterusnya

Langkah seterusnya adalah mempromosikan ”Kempen Berjalan 10,000 Langkah” di semua peringkat umur dan tempat dalam Daerah Pontian dan dalam Negeri Johor.

PP-31 Meningkatkan Aktiviti Fizikal melalui Kempen 10,000 Langkah di kalangan Masyarakat



-21st

October 2011

52

Chow TS, Low LL, Zuhaila MI, Cheang LF, Asma A, Zakiah K, Norlizawati S. Penang Hospital, Penang.


Highly Active Antiretroviral Therapy (HAART), a combination of at least 3 drugs from at least 2 different classes of antiretrovirals (ARVs), is used for treating Human Immunodeficiency Virus (HIV) disease. Adherence to complex HAART is critical as it is one of the major determinants to maintain sustainable virological suppression, hence prolonging patients‟ survival. Levels of adherence below 95% have been associated with poor virological and immunological response. Therefore, it is crucial to identify and overcome barriers that lead to non-adherence in order to sustain and prolong virological suppression.This study aimed to improve adherence in all new HIV-1 infected patients on HAART at the Infectious Disease Clinic Penang Hospital .


In this study, we measured the improvement in adherence by studying the record of attendance to Adherence Clinic and also the pill counts from every visit. The indicator is the percentage of patients newly started on HAART at 24-weeks post HAART with adherence of ≥ 95% and the standard was 100%

Number of patients with adherence ≥ 95% x 100% Total number of new HIV-1 infected patients on HAART


A retrospective study was done from 2005-2007 as a situational analysis. Subsequently post-remedial measures were undertaken with a new cohort from April 2008 to December 2009. Patients‟ consents were obtained before being enrolled into the study. All data were recorded in the patients‟ medication file and the Antiretroviral Therapy Monitoring Record.


During the pre-remedial period, a few factors which might contribute to non adherence were identified, namely complexity of the HAART regime (73.1% of patients were on non-combination pills), poor counseling for adherence (no adherence clinic), lack of communication between healthcare providers and patients (no helpline available after office hour) and lack of reviews in between appointments to meet the clinicians (4-6 months).

Strategy for Change

To improve patients‟ compliance and adherence as well as knowledge about disease and therapy, the study implemented a 10-visit adherence programme in between the visit to the clinician. In the programme, pill counts were performed, regime of combination pills was prescribed, counseling sessions including education were given and tested at the end of the programme, contact numbers of health care providers (including a 24-hour emergency contact) were given out. The programme involved clinicians, pharmacist counselors and nurse counselors.

Effects of Change

Defaulter rates had significantly reduced from 17% (pre-remedial) to 9.1% after remedial measures were undertaken. Patients had easier access to advice from physicians and pharmacist counselors with the provision of a contactable emergency number and also the 10-visit adherence programme. A simplified regime was also achieved in 70% of patients compared to 26.9% in pre-remedial analysis.

The Next Step

The programme will be continued and the implementation of the 10-visit adherence programme in retroviral patients on HAART especially in the first 2 years of therapy in the clinical setting will be practiced in all Infectious Disease Clinics throughoutthe country. The inclusion criteria would be extended to also include treatment-experienced HIV patients.

PP-32 Adherence Programme to Improve Treatment Response in HIV Treatment-Naïve Patients at Infectious Disease Clinic



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MJPHM

NOTICE TO CONTRIBUTORS

The Malaysian Journal of Public Health Medicine (MJPHM) welcomes articles of interest on all aspects of public health medicine in the art form of original papers, research communications and epidemic reports. Articles are accepted for publication on condition that they are contributed solely to the MJPHM. Neither are Editorial Board nor the Publishers accept responsibility for the views

and statements of authors expressed in their contributions.

Manuscripts: All manuscripts should be submitted in triplicate to:

Chief Editor,

Malaysian Journal of Public Health Medicine (MJPHM) United Nations University - International Institute for Global Health (UNU-IIGH) Universiti Kebangsaan Malaysia Medical Center (UKMMC) Jalan Yaacob Latif 56000 Cheras, Kuala Lumpur MALAYSIA

Manuscripts should be typed on one side of A4 paper and double-spaced throughout (including tables, legends and references). The first page should state the title of the paper, write appropriate name(s) of the author(s), degree and the name and address of the author for correspondence, abstract, introduction, methods, results and discussion (IMRAD) should follow. Paper may be submitted in Bahasa

Melayu and must be accompanied by an abstract in English.

Abstract: A summary of not more than 250 words should be provided in the second page. Below the

abstract, provide 3 to 10 keywords that will assist indexes in cross-indexing the article.

Introduction: State the purpose of the article, the rationale for the study or observation and the general

objectives. Do not review the subject extensively.

Material and Methods: Describe your selection of the observational of experimental subjects. Identify the methods, tools and apparatus (manufacturer‟s name and address) and procedures in sufficient detail to allow other researchers to repeat the study. Identify all drugs and chemicals used including generic name(s), dosage(s) and route(s) of administration. Statistical tests used should be given in sufficient detail and the use of any computer software should also be mentioned. For studies with ethical consideration such as clinical trials, studies done among minorities etc, the statement of approval from

relevant ethical committee has to be mentioned as set by the Helsinki Declaration.

Results: Present your results in logical sequences. If necessary, use appropriate tables or illustrations. Check the readability and accuracy of the statistical tests calculation.

Discussion: Emphasize the new and important aspects of the study. Discuss the implications of the findings, their limitations and relate the observations to other relevant studies.

Conclusion: Relate the conclusions with the objectives of the study but avoid conclusions nor supported

by data.

Acknowledgement: Acknowledge grants awarded in aid of the study case (state in number of the grant, name and location of the institution or organization) as well as person who have contributed significantly to the study.



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References: Use the form of reference adopted for the National Library of Medicine and used in Index Medicus. The citation is done by using the superscript Arabic numeral at the end of sentence. Try to avoid using abstracts as references. Unpublished observation, in press, accepted for publication and personal communication may not be used as references. List all authors when six or less, when seven or

more list only first three and add et al.

Standard Journal Article

1. Fungladda W, Sornmani S. Health behaviour, treatment for patients visiting malaria clinics in

Western Thailand. Southest Asian J Trop Med Pub Hth 1986; 17(3): 379-381.

2. Bundy DAP, Hall A, Adjei S, et al. Better health, nutrition and education for the school-aged children. Trans R Soc Trop Med Hyg 1997; 91: 1-2.

Books and other Monographs

Personal Author(s)

1. Colton T. Statistics in medicine. Little, Brown and Company: Boston, 1974.

Chapter in Book

1. DeFronzo RA Diabetic Nephropathy. In: Junior DP, Sherwin RS. (eds). Diabetic Mellitus. Connecticut: Appleton and Lange, 1997.

Agency Publication 1. Ministry of Health. Annual Report, 1999.

Electronic Material 1. Norai MS, Jumiatin O, Farizah H. Effective triaging in Putrajaya Health Clinic. Malaysian J Public

Health Med 2002, 2:45-9. Available from: http: www.pppkam.org.my/mjphm/detailarticle.asp ?id=31& issue=Vol2(2):2002 (accessed 1April 2004).

Tables and Illustrations: Arabic numerals should be used when numbering tables, illustrations and diagrams should be fully labeled and self-explanatory. All measurements should be reported using, metric system. Each table should be typed on a separated sheet of paper, doubles-spaced and numbered consecutively. Omit internal horizontal and vertical rules. The contents of all tables should be carefully checked to ensure that all the total and subtotal tally. Illustrations and diagrams should be referred to as “Figures” and numbered consecutively. Their approximate position in the text should be indicated. Legends and captions should be typed on separate sheets and diagrams are reproduced in black and white only.

Abbreviations: Use only standard abbreviations. The full term for which an abbreviation stands precede its first use in the text, unless it is a standard unit of measurement.

Copy of Journal: A copy of journal will be supplied free of charge to all authors.

http://www.pppkam.org.my/mjphm/detailarticle.asp?id=31&issue=Vol2(2):2002(accessed

Documents

Official Journal of Malaysian Public Health Physicians ... 11... · Official Journal of Malaysian Public Health Physicians’Association Deputy Chief Editor Volume 11(Suppl 5) 2011