​The push to optimise patient outcomes while reducing avoidable cost continues with improved processes for more procedures, including total hip replacement, total knee replacement and laparoscopic gallbladder removal.

In the face of an ageing population, value-driven care (VDC) – optimising patient outcomes and experience, while minimising public healthcare expenditure has never been more urgent.

Since 2017 when the concept of VDC was mooted by the Ministry of Health, clinicians in Singapore have been hard at work improving the quality of healthcare provision – and cross-institution collaboration has been a crucial success factor.

In 2020, teams at KK Women’s and Children’s Hospital and Singapore General Hospital (SGH) managed to reduce patients’ Length of Stay (LOS) and blood transfusion rates for Hysterectomy and Caesarean Section procedures through the sharing of clinical protocols and improvement initiatives.

The commitment to drive value has only gained more momentum as clinicians across various hospitals came together to further enhance clinical & operational processes for three other high-volume and high-cost procedures – total hip replacement (THR), total knee replacement (TKR) and laparoscopic cholecystectomy (minimally invasive gallbladder removal).

Elevating ortho-care
Total hip and knee replacements are two of the common major surgeries performed in Singapore, with about 4,000 patients undergoing TKR each year. With cases on the rise, ensuring efficient physical resource allocation is an obvious priority, say doctors from SGH, Changi General Hospital (CGH) and Sengkang General Hospital (SKH).

“The most effective way to reduce increasing healthcare cost is to shorten the patient’s length of hospital stay, while not compromising patient safety by discharging them early,” pointed out Dr Poon Kein Boon, Senior Consultant, Department of Orthopaedic Surgery, SKH.

Advances in surgical techniques has made this an easier reality. In recent years, a less invasive THR method called the direct anterior approach (DAA) has eliminated the need to cut through muscles for hip repair, thereby dramatically reducing patients’ LOS.

“It’s a reliable technique that gives patients less pain and faster recovery and allows them to be discharged within 24 hours,” said Dr Pang Hee Nee, Senior Consultant, Department of Orthopaedic Surgery, SGH.

Suitable patients who undergo DAA are supported with home visits by physiotherapists and community nurses within the first two weeks to assess their recovery progress.

Additionally, in 2019, SGH became the first hospital in Asia to launch an enhanced recovery after surgery (ERAS) pathway for carefully-selected TKR patients, allowing them to be safely discharged one day post-surgery.

It’s a team effort
Meanwhile at CGH, a multidisciplinary VDC workgroup came together in 2017 to study treatment protocols for TKR and THR.

“Through a process mapping exercise, our analysis showed that many services such as physiotherapy were only initiated after surgery, which could potentially lead to unnecessary delays in discharges,” said Dr Adrian Lau, Consultant of Orthopaedic Surgery, CGH.

This prompted the team to start pre-operative physiotherapy for TKR and familiarize patients early with post-surgery exercises.

The team also applied a Risk Assessment Prediction Tool (RAPT) to predict the discharge destination of patients prior to the surgery. This allowed clinicians to accurately allocate the required number of beds for patients and fast-track referrals to the community hospital to avoid unnecessary delays in discharge.

Additionally, they looked at ways to reduce the need for blood transfusions for TKR and THR, which increases the duration of hospitalisation and risk of infection.

As a result, the percentage of TKR and THR patients at CGH discharged in five days or less rose to 76 per cent, up from 53 per cent before, without a significant increase in 30-day readmission rates, or movement of patients to the community hospital, shared Dr Lau.

In a sharing session organised by the Office of Value Driven Care, SGH, CGH and SKH teams came together to review efforts. While SGH shared blood transfusion management protocols and details of the direct anterior approach technique with the other two hospitals, CGH contributed its Risk Assessment and Prediction Tool and TKR patient education brochure.

“The start of the programme was the most challenging as it required major changes in mindset of the patients and their families, allied health colleagues and the medical team, “said Dr Pang.

He added, “When they realised the good they are doing for the patients and the hospital, our collaborations became stronger and the program progressed even further.”

Better post-op management for laparoscopic cholecystectomy
Another procedure that has been put under value-driven evaluation is laparoscopic cholecystectomy, a minimally invasive form of gallbladder removal.

“Laparoscopic cholecystectomy is one of the most common general surgery operations performed.    It has a fast turnover with fairly predictable outcomes and processes that can be standardised,” said Associate Professor Chan Chung Yip, Head and Senior Consultant, Hepato-pancreato-biliary and Transplant Surgery, SGH.

While it is considered a low-risk surgery with many patients discharged within 24 hours, there are variations in post-operative care as the procedure can be carried out by surgeons in different sub-specialties and with different experiences and preferences. A reason for delayed discharge is due to patients’ reluctance to go home with a temporary drainage tube following surgery, even though they are well enough to do so.

As a result, SGH conducted department roadshows to provide feedback to individual surgeons on how they can increase value for laparoscopic cholecystectomy  and encourage timely discharge. The roadshows also served to educate clinicians on how drains can be removed early, and if needed, how patients can manage their drainage tube at home until it can be removed, thereby reducing delayed discharges.

Also, nurse-led discharge at SGH for short-stay patients who fulfil all criteria has proven crucial in ensuring timely discharge and turn-around of beds for new admissions. In such scenarios, nurses are be able to release patients whose conditions are assessed to be suitable for discharge. It hastens the discharge process and allows more patients to be admitted in the short stay ward. “This helps the nursing team effectively manage patient flow,” says Chang Pin Sun, Assistant Director of Nursing, Operating Theatres, SGH.

At two other SingHealth hospitals, more short stay ward beds were allocated to laparoscopic cholecystectomy patients. Administratively, laparoscopic cholecystectomy patients were also listed into the 23-hour ward by default with few exceptions. There are plans to have more short stay wards and increase its utilisation for laparoscopic cholecystectomy patients in the coming years.

The teams also reached out to a top performing hospital in laparoscopic cholecystectomy VDC to learn best practices that can be adopted for SingHealth, such as implementing a report card for individual surgeons.

“Our very committed, professional and efficient VDC team have made the whole undertaking very painless for me,” said Prof Chan.