Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Volume 11(Suppl 5) 2011
MJPHM
Official Journal of Malaysian
Public Health Physicians’Association
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
Dr. Lokman Hakim Sulaiman
Assoc. Prof. Dr Retneswari Masilamani
Assoc Prof. Dr. Mohamed Rusli Abdullah
Assc. Prof. Dr Saperi Sulong
Assc. Prof. Dr Maznah Dahlui
Dr. Roslan Johari
Dr. Othman Warijo
Dr. Norfazilah Ahmad
Dr. Amrizal Muhd Nur
University Putra Malaysia
Ministry of Health Malaysia
University Malaya
University Sains Malaysia
University Kebangsaan Malaysia
University Malaya
Ministry of Health Malaysia
Ministry of Health Malaysia
University Kebangsaan Malaysia
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: mjphm@pppkam.org.my
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Volume 11(Suppl 5) 2011
MJPHM
Official Journal of Malaysian
Public Health Physicians’Association
6th NATIONAL QUALITY ASSURANCE CONVENTION 2011
18-21 OCT 2011
DEWAN WAWASAN 2020, KANGAR, PERLIS
Organised by
Ministry of Health
Persatuan PakarIn
Perubatan
Kesihatan
Cooperation
with Awam Malaysia
Perlis State Health Department
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
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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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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
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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.
50
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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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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.
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.
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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.
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.
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Meningkatkan Kompetensi Pelatih Program Diploma
Pembantu Perubatan melalui Intervensi Simulasi Klinikal
Elengovan V, Nazri A, Yong KK, Zafri Y, Liew CF.
Bahagian Pengurusan Latihan, Kementerian Kesihatan Malaysia, Wilayah Persemutuan Putrajaya.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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.
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Meningkatkan Kehadiran Ibu Mengandung ke Klinik
Pergigian
Nor Sarah A, Suhaila AK, Nur Arliza P, Wan Mohd Ridzuan WJ.
Klinik Pergigian Peringgit, Melaka.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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%.
Proses Pengumpulan Maklumat
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.
Strategi Penambahbaikan
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
OP-05
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Reducing E-Prescription Error in a Hospital In-patient
Pharmacy
Wan Najbah NN, Ngan YS, Muhd Nor Hazli N, Ng KY, Ching MW, Tan HF.
Pharmacy Department, Putrajaya Hospital, Wilayah Persekutuan Putrajaya.
Selection of Opportunities for Improvement
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%.
Process of Gathering Information
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 selfadministered questionnaires to all doctors in wards. Following remedial measures, two more phases of data
collection were carried out to evaluate its effectiveness.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
OP-06
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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.
Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement

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%)
Process of Gathering Information
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).
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Menurunkan Kejadian Anemia di Kalangan Ibu Hamil pada
Usia Kandungan 36 Minggu
Norasikin M, Zaitun I, Roslenda M, Mazliza M, Rubiah L, Masriah M.
Pejabat Kesihatan Pontian, Johor.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Menurunkan prevalens anemia di kalangan ibu hamil pada usia kandungan 36 minggu. Standard yang ditetapkan
adalah kurang dari 10 %.
Proses Pengumpulan Maklumat
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).
Strategi Penambahbaikan
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 Penambahbaikan
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
OP-08
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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.
Pharmacy Department, Melaka Hospital, Melaka.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
BRAINetwork Centre for Neurocognitive Science, School of Health Sciences, Universiti Sains Malaysia, Kubang
Kerian, Kelantan.
Selection of Opportunities for Improvement
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%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Meningkatkan Peratusan Kepatuhan Terhadap Perawatan
Pesakit dengan Infusi Intravena di Wad Obstetriks &
Ginekologi
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 20082010 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.
Pengukuran Utama Penambahbaikan
Indikator yang dikenalpasti adalah peratusan kepatuhan penjagaan perawatan pesakit dengan infusi IV mengikut
SOP dengan standard lebih 80%.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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 Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
Hospital Seberang Jaya, Penang.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
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).
Key Measures for Improvement
We set a standard of LSCS without PPH at 90%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
Kuala Langat District Health Office, Selangor.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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 1 st 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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Meningkatkan Pengurusan yang Efektif bagi Ibu Hamil
dengan Anemia di Klinik Kesihatan
Suzaini MD, Junaidah I, Norhayati S, Nur Hazwani R, Rosnani R.
PKD Kangar, Perlis.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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).
Proses Pengumpulan Maklumat
Tiga kajian verifikasi dijalankan pada 2009 menggunakan kad KIK/1(b)/96 melibatkan 151 ibu hamil.
Analisis dan Interpretasi
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
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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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.
Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Indikator kajian ialah peratus pesanan luar jangka yang diterima dengan standard kurang dari 20%
Proses Pengumpulan Maklumat
Data pesanan luar jangka diperolehi dari buku daftar pesanan. Maklumat lain diperolehi melalui soal selidik dan
pemerhatian menggunakan borang pengumpulan data.
Analisis dan Interpretasi
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%.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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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.
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.
Key Measures for Improvement
Warfarin MTAC pharmacists in Labuan Hospital decided to set standard percentage of individual INR reading within
the targeted therapeutic range of at least 50%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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.
Department of Nursing and Intensive Care Unit, Taiping Hospital, Perak.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Meningkatkan Peratus Asma Bronkial Terkawal
Jayashree M, Shahrul Bariyah A, Norsiah MN, Ruzita S.
Klinik Kesihatan Pendang, Kedah.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Meningkatkan peratus asma bronkial terkawal di daerah Pendang. Piawaian yang ditetapkan ialah 80%.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Reducing Incidence of Severe Neonatal Jaundice
Gadung A, Christina BL, Adeline WSF, Juliana H, Hilda B, Iya R.
Kuching Divisional Health Office, Sarawak.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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).
Process of Gathering Information
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.
Analysis and Interpretation
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).
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Achieving International Normalised Ratio Targets and
Satisfaction of Warfarinised Patients
Subramaniam T1,Fudziah A1, Jeyaindran S2, Suliyana Y1, Lim SC1, Chong MF1, Cheng PL1, Teng SC1.
1
Department of Pharmacy, Kuala Lumpur Hospital.
2
Department of General Medicine, Kuala Lumpur Hospital, Wilayah Persekutuan Kuala Lumpur.
Selection of Opportunities for Improvement
Non-achievement of International Normalised Ratio (INR) among warfarinised patients results in poor clinical
outcomes and increased healthcare cost.
Key Measures for Improvement
The key measures for improvement were percentage of INR readings within target range (2 - 3), patients‟ warfarin
therapy knowledge and clinic waiting time.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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, Ng SL, Rosli A.
Department of Ophthalmology, Hospital Taiping, Perak.
Selection of Opportunities for Improvement
Diabetic Retinopathy (DR) is a microvascular complication of patients with diabetes. Those who have Severe NonProliferative 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.
Key Measures for Improvement
We aimed to reduce the above percentage of 50.2% to 20%, based on the target set by our department.
Process of Gathering Information
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).
Analysis and Interpretation
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.
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Mengurangkan Pencemaran Longkang dan Saliran Awam
oleh Sisa Minyak Terpakai
Azraei R, Ganggaraj A, Abdul Hamid MD.
Jabatan Kesihatan & Alam Sekitar, Dewan Bandaraya Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.
Pemilihan Peluang Untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Reducing the Number of Medication Administration Errors
in a General Paediatric Ward
Hiew CY, Lee ML.
Department of Pharmacy and Department of Paediatrics, Tuanku Ja’afar Hospital, Seremban, Negeri Sembilan.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
The Pharmacy Department had targeted to reduce any type of medication errors to 0%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Improving Proper Usage of Fetal Movement Chart among
Pregnant Women
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.
Key Measures for Improvement
The indicator of the study was percentage of proper usage of FMC and the standard set was 90%.
Process of Gathering Information
A cross sectional study was conducted on both pregnant women and healthcare staff. Data were collected using
interview questionnaire and observational method.
Analysis and Interpretation
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.
24
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
Department of Psychiatry, Tuanku Fauziah Hospital, Kangar, Perlis.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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 nonadherence. 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.
25
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
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.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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 dan Interpretasi
Analisis pemilihan rekabentuk didapati undian tertinggi (76.6%) adalah pakaian seragam berzip 6 inci yang diletak 2
sm dari puting ke bawah.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Increasing the Success Rate of Quit Smoking Clinic among
Adolescents
Arbaiah O, Marina MS, Zaleha J, Zainal AR, Hariyaton R.
Batu Pahat Health Clinic, Johor.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
To increase percentage of quit smoking among adolescents attending QSC in Batu Pahat to 80%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
approach is planned with the education department.
27
Continuous improvement of the module and
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Meningkatkan Pengesanan Komplikasi Pesakit Diabetes
yang Lengkap di Klinik Kesihatan
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%.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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%.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
28
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Reducing Rejection Rate of Blood Film Malaria Parasite
Sample Due to Unsatisfactory Smear from Emergency and
Trauma Department
Tchong FL, Nadiah AR, Noriah Y, Timothy B, Marilyn AA.
Department of Pathology, Sarawak General Hospital, Sarawak.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
This study aimed to reduce the rejection rate of BFMP sample from ETD, SGH to less than 5% by conducting
appropriate remedial action.
Process of Gathering Information
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.
Analysis and Interpretation
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.
29
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Improving the Passing Rate of Nursing Students in Anatomy
and Physiology Subjects
Tan SC, Chin SK, Khaw ES, Rogayah I, Lim JK.
College of Nursing Penang, Taiping, Kuantan & Kuching.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Mengurangkan Peratus Anemia Sederhana di Kalangan Ibu
Hamil Pada Minggu 36
Norazlina MN, Aida Rahayu AG, Shaebah MJ, Asma I, Noor Azhan A.
Pejabat Kesihatan Daerah Kubang Pasu, Kedah.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Standard yang ditetapkan adalah 18%.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
31
Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Reducing Central Venous Line Related Blood Stream
Infections among Paediatric Oncology Patients
Yeoh SL, Tan PY, Suhaila R, Azimah A, Nor Hafiza R.
Paediatric Oncology Unit, Paediatric Department, Hospital Pulau Pinang, Penang.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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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.
Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Improving Admission Time at a Maternity Patient
Assessment Centre
Mohd Azri MS, Lim GL, Puziah Y, Mohd Nasir O, Mohammad Faidzol T.
Sultan Abdul Halim Hospital, Sungai Petani, Kedah.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
Our aim was to achieve 75% of patients sent to the Antenatal Ward within one hour.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Malaysian Journal of Public Health Medicine, Vol. 11(Suppl 5) 2011
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Mengurangkan Peratus X-Ray Berulang yang Tinggi di
Klinik Pergigian
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.
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Mengurangkan Ketidakseimbangan Badan di kalangan
Pesakit Warga Tua di Wad Kronik
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.
Pengukuran Utama Penambahbaikan
Indikator kajian adalah mengurangkan peratusan pesakit yang mempunyai masalah keseimbangan badan (balance)
sehingga 60%.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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%).
Strategi Penambahbaikan
Langkah penambahbaikan seperti latihan kekuatan otot, koordinasi dan keseimbangan, gait, aktiviti rekriasi dan
pendidikan kesihatan telah diimplemintasikan.
Kesan Penambahbaikan
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.
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Minimising the Filling Errors in a Specialist Clinic
Pharmacy
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.
Key Measures for Improvement
This study analysed the factors which led to filling errors during office hours on five working days. The standard
set was 0% filling error.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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.
Department of Ophthalmology & Medical Social Unit,Hospital Raja Permaisuri Bainun (HRPB), Ipoh, Perak.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Menurunkan Peratusan Penolakan Kes Pembedahan
Dewan Bedah
Nurul Atikah H, Mohd Zahidi H, Kartini M, Sahaimi M, Nik Abdul Aziz RS.
Hospital Pasir Mas, Kelantan.
Pemilihan Peluang Untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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%.
Proses Pengumpulan Maklumat
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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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.
Department of Obstetrics and Gynaecology, Bintulu Hospital, Sarawak.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Improving Turn-Around-Time of Culture and Sensitivity
Testing
Wong MK, Abdullah A, Justin F.
Laboratory and Blood Bank Unit, Hospital Labuan, Wilayah Persekutuan Labuan.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
Two key measures for improvement, “Percentage of C&S TAT within Target (TAT%)” and “90 th 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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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.
Pharmacy Department, Kuala Lumpur Hospital, Kuala Lumpur.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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%.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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Increasing Retention Rate of Fissure Sealant among
Primary School Children
Hajar HR, Vijayamanohar K, Wan Aini WY, Nadia DB, Umi A.
Bangsar Dental Clinic, Federal Teritory of Kuala Lumpur.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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.
Kangar Health District Office, Perlis.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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%.
Process of Gathering Information
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.
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Improving Detection Rate of Diabetic Foot Problems Among
Patients with Diabetes
Samurah AR, Ganespathy P, Ibrahim AF, Molina J.
Kampung Pandan Health Clinic, Wilayah Persekutuan Kuala Lumpur.
Selection of Opportunities for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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.
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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.
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.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Menurunkan Kejadian Anemia Sederhana di Kalangan Ibu
Hamil
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.
Pengukuran Utama Penambahbaikan
Pejabat Kesihatan Daerah Kuala Terengganu telah menetapkan untuk mengurangkan kejadian anemia sederhana
ibu hamil pada 36 minggu kehamilan kepada kurang 20%.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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%).
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Delay In Induction of Labour with Oxytocin
Nik Azi Azuha NH, Norhayati A, Norizah M, Saluwani AH, Nuraini M.
Obstetrics and Gynaecology Department, Raja Perempuan Zainab II Hospital , Kota Bharu, Kelantan.
Selection of Opportunities for Improvement
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.
Key Measures for Improvement
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.
Process of Gathering Information
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.
Analysis and Interpretation
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 reassessment.
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Meningkatkan Pengetahuan Pesakit Tentang Perubahan
Rupa Ubat di Farmasi Pesakit Luar
Norhasmani M, Abby Ang SY, Rashidah AR, Omar O, Norfajariah I, Arzarizah A.
Farmasi Pesakit Luar Hospital Raub, Pahang.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
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.
Proses Pengumpulan Maklumat
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 praintervensi, data telah diambil bermula Disember 2009 sehingga Januari 2010 manakala kajian selepas intervensi di
jalankan bermula Mei sehingga Jun 2010.
Analisis dan Interpretasi
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Mengurangkan Kadar Kejadian LSCS Wound Breakdown
Anna T, Masni L, Lena C, Chua YL, Jeanyfer L, Mohd FA, Lucina L.
Hospital Tenom, Sabah.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Memastikan insiden LSCS Wound Breakdown kurang dari 15% dalam tempoh kajian selama 6 bulan.
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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.
Strategi Penambahbaikan
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.
Kesan Penambahbaikan
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.
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Meningkatkan Aktiviti Fizikal melalui Kempen 10,000
Langkah di kalangan Masyarakat
Norasikin M, Rubiah L, Masriah M, Zaitun I, Masliza M, Roslenda M.
Pejabat Kesihatan Pontian, Johor.
Pemilihan Peluang untuk Penambahbaikan
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.
Pengukuran Utama Penambahbaikan
Meningkatkan peratus responden yang mengamalkan aktiviti fizikal. Standard yang ditetapkan adalah melebihi 70
peratus (>70%).
Proses Pengumpulan Maklumat
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.
Analisis dan Interpretasi
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)
Strategi Penambahbaikan
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.
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Adherence Programme to Improve Treatment Response in
HIV Treatment-Naïve Patients at Infectious Disease Clinic
PP-32
Chow TS, Low LL, Zuhaila MI, Cheang LF, Asma A, Zakiah K, Norlizawati S.
Penang Hospital, Penang.
Selection of Opportunities for Improvement
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 .
Key Measures for Improvement
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%
Total number of new HIV-1 infected patients on HAART
x 100%
Process of Gathering Information
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.
Analysis and Interpretation
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 treatmentexperienced HIV patients.
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MJPHM
NOTICE TO CONTRIBUTORS
The Malaysian Journal of Public Health Medicine (MJPHM) welcomes articles of interest on all
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References: Use the form of reference adopted for the National Library of Medicine and used in Index
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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).
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