Pushing new frontiers

As SingHealth marks 200 years of Medicine in Singapore this year, we celebrate the advancement of the nursing profession, and the nurses who push the boundaries of nursing excellence to advance patient care.

Andrea Choh Chau Lin
Nurse Clinician, Singapore General Hospital (SGH)

Although she has been a nurse for 18 years, Andrea still remembers how nervous she felt when she had to perform her first intravenous (IV) cannulation on a patient. The process of inserting a cannula, or a thin tube, into the vein to administer a fluid into the bloodstream can evoke fear for a novice nurse and inflict pain on the patient, if not done well.

This has motivated Andrea, a member of SGH’s Nursing Quality Management team, and colleagues from the Institute of Advanced Nursing to develop a way to revolutionise the training and assessment of new nurses in the procedure.

Devising a serious game to measure physical dexterity is particularly challenging, but in just six months, they developed a prototype that is being piloted on new nurses, and could be deployed more widely by September 2021.

Nurses are able to practise healthcare communication by conversing with a virtual standardised patient to explain the procedure and provide reassurance. They will don a glove with a sensor woven into it while performing IV cannulation on a 3D printed arm. This arm is connected to a laptop. The glove can sense the pressure when a cannula is inserted, and the virtual patient will react and respond in real time while the procedure is being carried out. The arm is made to closely mimic that of a human’s, in terms of texture and feel — a significant improvement from the mannequin arm that is currently being used to train nurses.

To make the training more realistic, the team is planning to create various versions to more accurately reflect different patient profiles, such as male, female, or patients with hard-to-palpate veins. This project was awarded a grant by the Institute of Adult Learning, through the competitive InnovPlus Challenge.

Ma Victoria Dela Cruz Gonzalves
Nurse Clinician, Sengkang General Hospital (SKH)

Nurses at SKH used to have to empty urine drainage bags as frequently as every 10 minutes for patients undergoing a procedure called continuous bladder washout (CBWO), leaving them with little time to handle other tasks.

This changed after Victoria came up with a quality improvement (QI) project that reduced the frequency of emptying the urine drainage bags. This is the initiative she is most proud of among the various QI projects she has undertaken in her 22-year nursing career.

CBWO, which can last up to two days, is commonly performed after bladder or prostate surgery, or to remove and prevent blood clots in the bladder. Blood clots in the bladder can cause much discomfort, impede urination and lead to abdominal distension, and possible kidney damage. The procedure involves continuous irrigation of the bladder by passing saline through a catheter into the bladder, with the outflow collected in a urine drainage bag.

Victoria’s solution to replace the usual two-litre urine drainage bags with four-litre ones was implemented last year. She and her team have gone on to develop a prototype of an automated flow sensor to remotely monitor urine drainage bags and alert nurses when they are close to being filled.

Jesminder Kaur
Senior Staff Nurse, Central Sterile Services Department (CSSD), National Dental Centre Singapore

Faced with the prickly problem of a common dental instrument — known as a periodontal probe — breaking too often, Jesminder decided to do something about it.

The probe, which costs an average of $18 apiece, has to be discarded if its fragile pointed tip breaks. Apart from the cost of replacement, it is time-consuming for staff to check for breakages.

Jesminder co-led a team of fellow CSSD nurses to introduce a series of measures during the cleaning and sterilisation process that successfully reduced the median number of breakages per week at the CSSD from nine to just two. CSSD has also applied these interventions to the handling of other sharp probes and instruments.

Another project that Jesminder co-led in her two years at CSSD was to streamline the process of cleaning equipment trolleys. With the new workflow, the team was able to save on both manpower and utility costs.

Cedric Yeo Shan Jiao
Senior Staff Nurse, Singapore National Eye Centre (SNEC)

A brainchild of the SNEC Digital Transformation Office headed by Associate Professor Gavin Tan, Senior Consultant at SNEC, EySee is a mobile application that tests visual acuity. It is currently in the prototype phase. The idea for such a tool was mooted during the “Circuit Breaker” period last year, with the aim of reducing patients’ waiting time at eye clinics and minimising the risk of exposure to COVID-19.

In addition to his clinical duties, Cedric has been researching the EySee app since March this year. As a member of SNEC’s Nursing Informatics Department, set up in 2018, he is also involved in recruiting patients for a clinical study to validate the reliability of the app.

The app is expected to be ready for public use by 2022. He and his colleagues have also begun work on other projects, such as a chatbot function to enable patients to ask questions online before and after an eye operation.

Stacey Chong
Nurse Clinician, Changi General Hospital (CGH)

Developing a mobile application was a challenging experience for Stacey, but she is all ready to tackle more apps if they can contribute to educating nurses.

The app she co-developed, called Improving Triage in the Emergency Department (ITED), is on trial at CGH’s Emergency Department (ED) to train and assess new nurses in triage skills.

Triage is a process that ED nurses undertake to prioritise patients according to how urgent and serious their illnesses are. Doing triage competently and accurately, including asking the right questions, ensures that patients in need of urgent attention are seen by doctors quickly and that resources are used efficiently.

Under the guidance of ED doctors and with the support of her peers, Stacey worked with a vendor to build the app. The app includes videos that simulate the conditions of patients in real life. The user then needs to ask the relevant questions that can be used to assess the condition of the patients. The app is able to capture the questions asked and uses artificial intelligence to simulate patient responses. Users will receive real-time feedback on how they fared. The project was awarded the InnovPlus Challenge Award, organised by the Institute of Adult Learning Singapore, which provided a grant to develop the app.

Lynda Hung Yit Sim
Nurse Manager, Punggol Polyclinic, SingHealth Polyclinics

Tapping into healthcare technology, Lynda worked with engineers on a project to enable patients seeking certain services at SingHealth Polyclinics to fill in pre-visit online questionnaires. This has saved time for clinical staff and received positive feedback from users.

The services include cervical cancer screening, antenatal screening, family planning as well as child immunisation and travel medicine vaccination services.

The project required Lynda to first retrieve the relevant questionnaires from the Sunrise Clinical Manager (SCM), an Electronic Medical Record software. She then collaborated with the HealthHub IT team to ensure that responses are successfully transferred to SCM. This significantly improves efficiency as clinical staff no longer need to enter the information manually.

Along with an SMS to remind them of their upcoming appointments, patients are asked to fill in the pre-visit questionnaires via SingHealth’s Health Buddy app, or the Ministry of Health’s HealthHub portal or app before visiting the clinic.

More than 22,000 patients have chosen to fill in these questionnaires since they became available in July 2020. All patients surveyed found them to be useful.