With their ears and eyes on the ground, nurses are often best placed to spot bottlenecks and inefficiencies in processes that hamper the smooth running of their wards or clinics. At Singapore General Hospital (SGH), nurses and their colleagues in other disciplines regularly volunteer to brainstorm for ways to smoothen processes. Doing so also leads to better communication and understanding among different departments across SGH. Three of these projects took the highest awards at the twice-yearly in-house IQC assessments, which are run in conjunction with Singapore Productivity Centre.

Hands that go, “Ouch!”

Finding the right vein — typically at the wrist — and then inserting and guiding a needle with a small plastic tube into it for medications and fluids to be delivered can be a scary experience for a new nurse.

The procedure must be done swiftly and accurately, otherwise, ‘fishing’ or repeatedly poking to find a suitable vein can cause pain and bruising or, worse, phlebitis (inflammation of the vein).

One of the most important nursing skills, intravenous (IV) cannulation is not easy to master even with the rigorous training that nurses undergo. To reduce the incidence of complications and shorten the time to attain mastery of cannulation, an SGH team developed a training system called IV NIMBLE (Intravenous Nursing Innovation for Mobility-based Learning) that employs digital technology and data analytics.

“We hope new nurses and even medical students will feel more confident and be better equipped to perform cannulation after training on IV NIMBLE,” said Ms Andrea Choh, Senior Nurse Manager, SGH (above, left). “We also aim to reduce complications like bruising and inflammation that can occur when the cannula is inserted incorrectly,” added Ms Choh, the project lead.

A virtual patient avatar that responds to conversation, the system includes a pressure sensor and a 3D-printed hand with changeable materials to mimic various types of muscle, skin and veins. It is able to gauge the pressure exerted, how the cannula is inserted, react when the cannula is inserted wrongly, and show bruising and articulate pain.

Conventional training, in contrast, is unrealistic as it involves inserting the cannula into a silicone mannequin arm, which is modelled on a male sportsman with veins that are obvious and easy to locate. In reality, nurses need to cannulate on many types of arms, with different types of skin, muscle, tissue and veins. “Elderly patients, for one, have thinner skin, thinner veins,” said Ms Choh.

The conventional training arm cannot ‘feel’ pressure or resistance as it is static and does not provide sensory and other feedback for review and identification of areas for improvement. The system also trains students in speaking to patients by capturing interactions with the avatar for review.

An immersive gamified training module co-developed with industry partners, Serious Games Asia (SGA) and Microtube Technologies, the system lets students train at increasingly difficult levels of the procedure. In a June–July 2021 trial, 120 nurses underwent IV NIMBLE training, with the results showing a 74–76 per cent first-time cannulation success rate, and the ability of the avatar to converse with nurses speaking in different accents, reflecting the countries that SGH nurses come from.

Based on feedback from the pilot, the second-generation NIMBLE is able to operate wirelessly, have four virtual patient avatars and 3D-printed hands with commonly seen medical conditions such as elderly patients with fragile skin. Farther out, the system can be adapted for training of other skills like venepuncture for blood collection, chest tube insertion and other invasive procedures, said Ms Choh.

Velcro, buttons are no-nos

For patients, surgical gowns must be comfortable, easy to wear, safe and protect their modesty. For the medical team, the gown must serve other purposes — provide easy access to intravenous lines, urinary catheters and wound-drainage tubings, wounds for dressing, is easy to put on and remove, durable and safe. At the same time, hospital gowns, including for surgery, are ordered and supplied by the thousands at a time. Like staff uniforms, patient gowns are made to last many years.

The gown was revamped in 2019 when a new supply contract for it was due, with feedback taken in its redesign, said Nurse Clinician Huang Liwen (below, left), who led a 10-member team to look into the redesign. She said: “We wanted a nice balance between safety and practicality, yet also for the gown to be functional.”

The old gown had too many ties at the back, which can confuse or pose challenges. Velcro fastenings may be easy to use, but they cannot withstand repeated heavy washing and ironing. Buttons may come loose and get lost in surgical incisions. For breast reconstruction patients, side slits are important for easy access to wounds.

The redesign took six months, with feedback from the team’s mainly theatre and surgical ward nurses. The final product was a green gown with a lower neckline, allowing nurses and doctors easy access to invasive lines. It can also be worn sleeveless, depending on the needs of the patient. The third feature — a side slit — allows medical staff easy access to wounds. The number of ties was also reduced and placed at the shoulders and sides so patients can easily don the gown by themselves. This design also better protects patients’ modesty, added Ms Huang, noting that patients’ satisfaction rate rose to 80 per cent from 50 per cent in their pilot study.

But the entire process — from conceptualisation to production — did not come without challenges, with the team going through several prototypes before landing on the final solution. Logistical issues brought about by the pandemic caused delays to the production and shipment of the gowns. Eventually, about 6,000 new gowns were rolled out hospitalwide in March 2023.

Carers are hydration partners

Complications from dehydration can contribute to the overall functional decline of elderly patients. Patients often do not drink or eat enough, partly because their taste and swallowing functions change as they age. Some also worry about drinking too much and having to call for nurses’ help to go to the toilet. “Inadequate hydration and oral intake can impede patients’ recovery, and increases the risk of functional decline, contributing to a longer hospital stay,” said Dr Rachel Ng, Consultant, Department of Geriatric Medicine, SGH (below, right).

While patients are given a target amount of water to drink every day, keeping track of patients’ fluid intake can often be a challenge, especially as their different medical conditions require different hydration needs, said Ms Aines Manickam, Nurse Clinician, SGH (above, left). “Realising how frail most patients are and how often their water intake is inadequate, we tried our best to address this issue,” said Ms Manickam, who led a group of mostly ward nurses in a project to improve patient hydration.

The team’s first solutions included introducing fluid rounds, during which nurses regularly give patients water to drink, and posters to remind staff to conduct the rounds. Another initiative was the use of flip charts highlighting the importance of hydration. These charts — placed at patients’ bedsides — contain simple pictures and words printed in four languages, thus surmounting some language barriers. A fluid schedule in the flip chart also helps nurses monitor the patient’s fluid intake.

But perhaps one of the more critical interventions, said Ms Manickam, was in educating nursing staff — and caregivers — on the importance of adequate hydration. It is an effort that requires all hands on deck and a “multi-component, multidisciplinary approach” across departments, said Dr Ng. The result after three months showed an increase in the number of elderly patients who met their daily fluid requirements from 15 to 60 per cent.

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