Reducing insulin omission errors among patients with diabetes mellitus in general surgical wards: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Omission of insulin, a high-alert medication with one of the highest locally reported errors, could lead to severe hyperglycemia, which could result in coma or death if not treated timeously. This study aimed to identify, evaluate, and implement strategies to reduce the occurrence of insulin omission errors in diabetic adult patients requiring insulin. METHODS: This project followed the JBI Evidence Implementation Framework and conducted context analysis, strategy implementation, and evaluation of outcomes according to evidence-based quality indicators. The JBI PACES and JBI GRiP situational analysis tools were used to support data collection and implementation planning. There was one evidence-based criterion and five sub-criteria, with a sample size of 22 patients. RESULTS: There was increased compliance with best practices to reduce interruptions and distractions from baseline audit (50%) to follow-up audits 1 (45.4%) and 2 (31.8%), and no insulin omission incidences during the implementation period. In the post-implementation analysis, there were notable improvements in compliance with strategies related to nurses; however, reduced compliance was observed related to patients. Key barriers to implementation included patients still disturbing nurses despite the nurses wearing the medication vests and patients forgetting instructions not to disturb nurses during medication administration. Strategies to improve compliance included ensuring coverage in each cubicle during insulin preparation and administration, tending to patients' needs prior to insulin administration, and use of posters as reminders. CONCLUSIONS: There was an overall increase in compliance with best practice to reduce interruptions and distractions and no insulin omission incidences related to interruptions and distractions during the implementation phase. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A219.

Nurse-led speech therapist referral initiative for older adult patients at risk of dysphagia: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Dysphagia is common among older patients, affecting their nutritional status, hospital readmission, length of hospital stay, and hospitalization costs. Nurses can play a key role in early identification of dysphagia through systematic screening. This project sought to (i) achieve 80% compliance among nurses in using the 4-point questionnaire test (4QT) swallow screening test on patients and (ii) ensure all patients screening positive for dysphagia were referred to a speech therapist within 1 day. METHODS: A short swallow screening tool was adapted from an evidence-based screening tool, the 4QT, by a team of speech therapists, a geriatrician, and a geriatric trained nurse. Ward nurses were then trained on using the tool to screen older patients upon admission or transfer to another ward. The project used the JBI Evidence Implementation Framework, which involved pre and post audits and feedback to evaluate compliance with best practice. RESULTS: Compliance increased in the use of the short swallow screening tool, rising from 64% ( n  = 25) in the baseline audit to 71% ( n  = 34) in the follow-up audit. However, there was a decrease in the referral of patients who screened positive for dysphagia to speech therapists, with the rate dropping from 92% ( n  = 12) to 86% ( n  = 12). All patients ( n  = 12) from both baseline and follow-up audits were referred to a speech therapist within 1 day of admission/transfer post-implementation compared with 70% ( n  = 7) at pre-implementation. CONCLUSIONS: This project applied evidence-based recommendations to clinical practice and improved patient outcomes. The nurses facilitated timely referrals to speech therapists for further assessment and intervention, which was useful in the clinical context. The nurses continue to use the screening tool routinely to prevent dysphagia complications among geriatric patients.

Prevent postoperative urinary retention in day surgery adult patients: evidence-based quality improvement project.

INTRODUCTION AND AIMS: Postoperative urinary retention (POUR) is a complication that often leads to adverse outcomes and prolonged hospital stay if treatment is delayed. The aim of this project was to improve the competence of nurses in the provision of preoperative POUR education and ensure all patients received preoperative POUR education, and hence reduce the incidence of POUR. METHODS: The evidence-based quality improvement project utilized JBI's Practical Application of Clinical Evidence System and Getting Research into Practice module, adopting two POUR best practice recommendations and two audit criteria. The first criterion was for nurses to conduct preoperative education on POUR and the second criterion was to initiate early ambulation of postoperative patients. The project was implemented in three phases from June 2019 to August 2020 in short-stayer and day surgery wards. RESULTS: Criteria 1 and 2 revealed low compliance of 0 and 30%, respectively, during preimplementation audit. There were significant improvements in the first and second cycles of postimplementation audit for both criteria 1 and 2. Our results indicated that most of the patients who were ambulated early were able to void urine. However, there were a few incidents of urinary retention reported despite early ambulation. Following the audit of the third cycle of postimplementation, the compliance for both criteria were found to be satisfactory (criteria 1: 87%, criteria 2: 82%). CONCLUSION: The implementation of the evidence-based quality improvement project reduced the incidence of POUR. A standardized management would enable nurses to provide consistency in care and effective management and hence prevent the occurrence of POUR.

Increasing patient participation in hand hygiene practices in adult surgical wards in a tertiary institution: a best practice implementation project.

INTRODUCTION: The WHO states that hospital-acquired infections may be transmitted through contaminated hands. Practicing hand hygiene using alcohol-based handrub or soap and water reduces harmful organisms. The Joanna Briggs Institute (JBI) best practice recommends empowering patients with hand hygiene knowledge and engaging their involvement to strengthen hand hygiene practices. AIMS: The aim of this project was to improve hand hygiene among surgical inpatients. METHODS: This evidence-based quality improvement project was conducted in three phases: the baseline audit, implementing best practice, and the postimplementation audit. Participants were patients hospitalized in three surgical wards of a 1200-bed acute care tertiary hospital. This project utilized the online JBI Practical Application of Clinical Evidence System and The Getting Research into Practice program to identify barriers and strategies. Nurses provided patients with an education pamphlet and regularly reminded them to improve their hand hygiene practices. RESULTS: Ninety-four patients were audited between April and June 2018. Patients' hand hygiene practices improved from 19.1% at baseline audit to 61.7% (P < 0.01) at first follow-up audit. Patients' hand hygiene improved from 48.9 to 72.3% (P = 0.03) before meals, and from 92.6 to 98.9% (P = 0.65) after toileting. The proportion of patients who received a hand hygiene information leaflet in an appropriate language increased from 64.9 to 89.4% (P < 0.01). CONCLUSION: Patients' involvement in the hand hygiene program has significantly improved their hand hygiene practices. Patient education and patient information leaflet continue to be an effective strategy to improve knowledge and practices.

Maintaining oral hydration in older adults in surgical wards: a best practice implementation project.

INTRODUCTION AND AIM: Oral hydration is essential in older adults as poor hydration can complicate existing medical conditions and increase morbidity. Older adults in surgical wards are at risk of dehydration due to insufficient fluid consumption. The aim of this project is to ensure patients aged 65 years and above are adequately hydrated. METHODS: The current project was conducted over 7 months from February to August 2019 and involved pre and postimplementation audits to ensure compliance with best practice. The Joanna Briggs Institute Practical Application of Clinical Evidence System and the Getting Research into Practice tools were used as a guide. Audits were conducted at four surgical wards with a sample of 42 patients at each audit. The measures implemented include educating nurses on the importance of oral hydration in older adult patients and labelling water jugs to encourage fluid intake among these patients. RESULTS: Nurses' compliance in monitoring older adult patients' daily fluid intake increased from 5 to 76% at follow-up audit (P < 0.05). In addition, the average amount of fluid consumed over 3 days increased from 858.23 to 1037.50 ml. CONCLUSION: This project demonstrated a significant increase in oral fluid intake among older adult patients during hospitalization and their understanding of adequate fluid intake. Nurses play an important role in ensuring adequate amounts of daily fluid intake by these patients.

Patients performing lower limb exercises in an orthopedic ward: a best practice implementation project.

AIMS: The evidence-based project sought to educate patients on doing lower limb exercises within 24 h of their admissions to the ward. Patients spend most of their time in bed during their hospital stays, which imposes negative outcomes due to inactivity, such as risks of reduced muscle mass and deconditioning, which may further implicate patients' conditions. METHODS: The project occurred in three phases over a period of 18 months. The project was undertaken in an orthopedic ward of an acute tertiary hospital. A preimplementation and postimplementation audit strategy using the Joanna Briggs Institute's Practical Application of Clinical Evidence System was conducted on a sample of 20 adult patients. The Getting Research into Practice framework was utilized to analyze the barriers and gaps encountered in the clinical ground. RESULTS: The baseline audit result revealed that only 35% of the patients received education on the exercise program and that there was poor compliance on nursing documentation of the intervention in daily note-free texts. Following the implementation, there was an improvement in nurses' documentation compliance. In follow-up audits one and two, the nurses achieved compliance rates of 60 and 90% in nursing documentation, respectively. CONCLUSION: Overall, there were improvements in provision of lower limb exercise education to patients. This project has demonstrated that patients were willing to exercise during hospitalization. Nurses play a significant role in providing early education to patients to do simple exercises. The implementation of the evidence-based project may increase the awareness of the importance of exercises to minimize hospital-acquired deconditioning and functional declines among ward nurses and patients.

Enhancing the verbal handover process for nurses in inpatient orthopedic wards: a best practice implementation project.

OBJECTIVES: This evidence-based quality improvement project aimed to evaluate the effectiveness of a handover guide in improving handovers from registered nurses to enrolled nurses. INTRODUCTION: Nursing handover involves the transfer of the responsibility of care for a patient from one nurse to another. Handover techniques vary in different healthcare organizations. Non-standardized, incomplete handovers can lead to delays or errors in treatment, increased lengths of stay, and poor health outcomes. METHODS: This project was conducted in two orthopedic wards of a tertiary hospital, and occurred in four phases over 12 months. The project utilized the JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) tools. RESULTS: The baseline audit in March 2017 revealed a poor compliance in handover of essential patient information. The post-intervention audit showed a significant increase (P < 0.001) in the compliance of handover of essential patient information. Registered nurses' handovers of patient information to enrolled nurses improved from 11% to 27% (P < 0.000). Verbal face-to-face handovers occurred throughout the implementation. Eighty-two per cent of the nurses felt that the handover guide had reduced the number of monitoring errors and delays in treatment. CONCLUSION: The project has successfully improved nurses' clinical handovers and contributed to safe patient care. Further audits are required to sustain the evidence-based practice change. Nursing leaders play a significant role in supporting the project and building a positive evidence-based practice environment.

Reducing contamination of midstream urine samples through standardized collection processes: a best practice implementation project.

OBJECTIVE: The objective of this project is to decrease the rates of midstream urine sample contamination through standardization of evidence-based techniques among nurses. INTRODUCTION: Urinary tract infection is a prevalent health problem worldwide. The diagnosis and treatment of urinary tract infection depend on a thorough physical examination and the results of an uncontaminated midstream specimen of urine. However, improper techniques used in the collection often cause sample contamination, leading to delayed diagnosis and the use of inappropriate antibiotics for treatment. As nurses are at the forefront of care delivery, they are involved in reducing the rates of midstream urine sample contamination. Thus, the use of an evidence-based approach to standardize collection of midstream urine culture is crucial for the provision of higher-quality patient care. METHODS: Education sessions were delivered to the nurses and an evidence-informed standardized patient education leaflet was crafted by the project team for implementation. With a sample size of 30 nurses and patients, the project took place in a 21-bed adult surgical ward in a hospital in Singapore. The JBI Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) programs were used to implement the evidence-based project. The project was implemented in three phases from October 2018 to January 2019. A standardized audit tool devised from JBI PACES was used for the audits in this project. The rates of midstream urine specimen contamination and the knowledge of nurses were also monitored. RESULTS: The baseline audit revealed that the nursing staff required educational sessions to improve their knowledge of midstream urine sample collection. Aside from criteria 1,3 and 4, the remaining criteria achieved compliance of more than 80%. The criteria below 80% compliance became the main focus of the project interventions. At follow-up cycle 1, all criteria achieved at least 80% compliance except criteria 4 and 5, which achieved 73% and 69% compliance, respectively. At the three-month post implementation audit, all criteria achieved a compliance rate of at least 80%. Fisher's exact test was carried out, and statistical significance of the results was achieved (p < 0.001) when compared to baseline audit. The rates of midstream urine specimen contamination also significantly decreased from 40% at the baseline audit to 20% at the third-month post implementation audit. Nurses' knowledge markedly improved as measured by the three-question quiz. CONCLUSION: This evidence-based implementation project highlights the effectiveness of the JBI PACES and GRiP processes for initiating best practice within a nursing environment. The use of JBI best-practice recommendations to standardize methods for midstream urine specimen collection effectively reduced the rates of midstream urine contamination.

Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project.

OBJECTIVES: The objective of this evidence-based quality improvement project was to improve clinical nursing handovers between registered nurses. INTRODUCTION: Clinical nursing handovers transfer critical information about the patient's care to oncoming shift nurses. Nurses use structured handover tools to handover patient information. In three adult surgical wards of a Singapore tertiary hospital, a lack of consistency was found in the local handover process when shifts changed. These resulted in ineffective handovers and compromised the patient's safety. Thus, evidence-based interventions were needed so that patient handovers and continuity in safe patient care could improve. METHODS: This project was implemented in three phases from January 2017 to November 2017 at three adult surgical wards of a tertiary hospital, utilizing the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) module. The pre- and post-implementation audits were conducted using JBI PACES audit criteria. An evidence-based four-pronged approach was employed, including adequate human resource coverage during handovers, a structured and standardized handover, visual cues and a teaching video. RESULTS: The results of the post-implementation audit of nurses performing handovers (n = 33) showed that handovers using standardized documentation improved from 0% to 21.0% (p = 0.005), which was statistically significant. However, handovers of detailed observations of patients improved from 72.7% to 87.9% (p = 0.215) and handovers of relevant history of patients improved slightly from 93.9% to 97.0% (p = 1.000) but was not statistically significant. Medication error incidents related to handovers was reduced by 72% over a six-month period. CONCLUSION: The multi-modal approach improved the comprehensiveness and completeness of clinical nursing handovers. These strategies had a significant effect on reducing medication errors related to handovers.

The Progression and Future of Nursing in Singapore: A Descriptive Qualitative Study.

Introduction: Nursing professionalism and nursing identity are important for retention of nurses. Despite of much attention on nurses in Singapore, there is still a shortage of nurses. This study aims to understand the perceptions of the progression and future of the nursing profession in Singapore. Methodology: A descriptive qualitative study design was used. The participants were 20 nurse educators, clinical nurses, and student nurses. Data were collected through focus group and online interviews and analyzed thematically. Results: Nurses felt a need to bridge the theory-practice gap and various factors to the underlying cause of the shortage of nurses were highlighted. Nurses shared their desires to see greater autonomy among nurses and a greater focus on community nursing in the future. Discussion: Collaboration between nurse academics and clinical nurses may bridge the theory-practice gap. To reduce the issue of the shortage of nurses, efforts to promote nursing professionalism are required.

Prevention of heel pressure ulcers among adult patients in orthopaedic wards: an evidence-based implementation project.

BACKGROUND: Immobility and prolonged bed rest often lead to heel pressure ulcers in patients. A point prevalence audit undertaken in the orthopaedic wards of a Singapore tertiary hospital reported that 6 out of 30 patients who were audited had mild to blanching redness on their heels. AIMS: The evidence-based project sought to achieve 80% compliance from nurses to perform heel off-loading practice and a 50% reduction in the occurrence of heel pressure ulcers. METHODS: The project, lasting two years, was undertaken in two orthopaedic wards and utilized a pre- and post-implementation audit strategy using the Joanna Briggs Institute on-line 'Practical Application of Clinical Evidence System' and 'Getting Research into Practice' programs. Implementation occurred in four phases and involved a sample consisting of 30 adult patients. RESULTS: Nurses' compliance with performing heel off-loading techniques increased. The post-implementation audit showed 93.3% compliance of nurses undertaking heel off-loading techniques in the subsequent four follow-up audits. Meanwhile, the compliance with documentation increased from 63.3% to 86.7%. The project resulted in more than 50% reduction in stage one heel pressure ulcers. CONCLUSION: The implementation of heel off-loading techniques significantly reduced the incidences of heel pressure ulcers in orthopaedic wards.

Improving the accuracy of fluid intake charting through patient involvement in an adult surgical ward: a best practice implementation project.

OBJECTIVES: The main objective of this evidence-based utilization project was to improve the accuracy of fluid intake charting through patient involvement. INTRODUCTION: The accurate documentation and maintenance of fluid balance charts constitute an integral part of nursing care. However, inaccuracies in fluid balance charting by nurses often occur. Inaccurate charting can result in delayed interventions, affecting the safety of patients. It has been found that fluid intake charting in an acute surgical inpatient ward is highly inaccurate. Many expressions of dissatisfaction are evident among medical healthcare professionals and patients regarding the accurate updating of the charts. Therefore, evidence-based measures need to be implemented in order to improve the safety of patient care through accurate recording of patients' fluid intake. METHODS: The project took place in a 21-bed acute surgical ward which had 30 patients. The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) tools were used to implement the evidence-based project. A pre- and post- audit methodology congruent with the framework was applied. The project was implemented in three phases from April to September 2016. The audit criteria obtained from JBI-PACES were used. The project's primary focus was to harness patient involvement in improving the accuracy of fluid intake charting. RESULTS: Criteria 1 and 2 revealed low levels of compliance during the pre-implementation audit, 3% and 10%, respectively. There were significant improvements one month post-implementation for both Criteria 1 and 2, 100% and 87%, also respectively. Fisher's exact test was carried out and the statistical significance of the results was achieved (p < 0.001), compared to the pre-implementation audit. At six months post-implementation, the audit found that both criteria were adequately sustained as a practice in the ward (Criterion 1: 100%, Criterion 2: 83%). CONCLUSIONS: This project has demonstrated the effectiveness of improving the accuracy of fluid intake charting through patient involvement. The use of JBI-PACES and GRiP has allowed the effective utilization of evidence in practice. It has also provided evidence that effective engagement of the ground nurses and stakeholders coupled with the commitment of change champions and ground nurses can contribute to improving practice in a highly demanding acute care setting and lead to healthcare success.

Patient Satisfaction Is Linked to Nursing Workload in a Singapore Hospital.

No studies have examined the association between patient satisfaction and the allocation of nursing care hours using a workload management system. The aim of this study is to examine the correlation between inpatients' perceived satisfaction with nursing care and nursing workload management in a Singapore hospital. A secondary data analysis was performed based on the results of 270 patients' perceived satisfaction measured by the Revised Humane Caring Scale and nursing workload management data extracted from the TrendCare Patient Acuity System. Data were collected from March to October 2013. There were weak positive ( rs = .212 to rs = .120) and negative ( rs = -.120 to rs = -.196) correlations between patient satisfaction and nursing workload. Nursing leaders should build positive work environment through maximizing efficient resource allocation and adequate staffing to deliver safe patient care. Future studies could involve other patient outcomes such as incidences of fall and pressure ulcer.

Patient-centred hand hygiene information in orthopaedics units: an evidence-based implementation project.

AIM: This project aimed to improve patients' knowledge on the importance of hand hygiene. It involved providing patients with a patient and family education on the importance of hand hygiene using a patient information leaflet that introduces the rationale of hand hygiene, possible consequences of poor hand hygiene, and the seven steps of hand hygiene. METHODS: This projected used a preimplementation and postimplementation audit strategy using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research Into Practice programs. The implementation occurred in three phases over a period of 6 months from January 2014 to June 2014. The audits took place in two orthopaedic wards in a large acute care setting tertiary hospital in Singapore and involved a sample size of 54 patients. It involved going through the medical records of the cases, assessment of patient knowledge based on the audit criteria, and checking if the patients received the patient information leaflet on hand hygiene. RESULTS: The postimplementation audit found significant improvements in all three audit criteria. The percentage of patients who demonstrated knowledge in the importance of hand hygiene saw an improvement of 48.1%. There was an improvement of 44.5% in nurses' compliance to the documentation of patient education being carried out. The percentage of patients who received a patient information leaflet on hand hygiene saw an increase of 36.1%. CONCLUSION: This project demonstrated that a preimplementation and postimplementation audit is a viable method to implement change and translate evidence into practice. Through this project, patients gained an understanding on the importance of hand hygiene and could take better ownership of their well being. This may potentially improve hospitalization experience and benefit health outcomes. The positive results of this project are contributed by the enthusiastic involvement of all the stakeholders, from patients and their caregivers to the bedside nurses and nursing leaders. The sustenance will be an ongoing challenge to the project.

Securement of the indwelling urinary catheter for adult patients: a best practice implementation.

AIM: The evidence-based project sought to improve knowledge and practice in the care and securement of indwelling urinary catheters. METHODS: The project utilized a pre and post-implementation audit strategy, with the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The best practice recommendations on the care and securement of indwelling urinary catheters were retrieved from the Joanna Briggs Institute Clinical Online Network of Evidence for Care and Therapeutics database. A proposed urinary catheter securement practice, which included the use of a specifically designed securement device, was developed and implemented based on these recommendations. The implemented practice was evaluated with an audit tool which comprised two criteria recommended by the Joanna Briggs Institute Practical Application of Clinical Evidence System on the topic: Appropriate Catheter Use and Management. Audit criteria outcomes included staff compliance to training for urinary catheter securement and care and effectiveness of the implemented practice utilized to secure urinary catheters. The project was conducted in a general surgical ward over a period of 14 months, from December 2013 to January 2015. A sample of 30 inpatients was recruited at each audit phase. The sample size was decided based on recommendations from the Joint Commission International guidelines. RESULTS: A comparison between baseline and post-implementation audit findings indicated significant improvements in both audit criteria outcomes. For the first criterion, 100% compliance (P < 0.001) was achieved with all ward nurses being trained in application and care of the proposed urinary catheter securement practice. Criterion 2, which measured the effectiveness of the implemented practice, showed a nine-fold improvement from 10 to 90% (P < 0.001). A sustenance audit conducted 6 months post-implementation showed that compliance rates maintained at 100% for criterion 1 (P < 0.001), with further improvement from 90 to 100% for criterion 2 (P < 0.001). CONCLUSION: The proposed indwelling urinary catheter securement practice is an effective alternative to existing nursing practices. The use of a specifically designed securement device is found to complement and enhance the quality of urinary catheter securement. Nurses exhibited greater competency and knowledge in the application and care for urinary catheter securement.

A descriptive quantitative study on multi-ethnic patient satisfaction with nursing care measured by the Revised Humane Caring Scale.

AIM: To determine patients' satisfaction with nursing care during hospitalization. BACKGROUND: Limited studies reporting patients' satisfaction with quality of nursing care in Singapore. METHOD: A descriptive study was conducted in a tertiary hospital in Singapore. RESULTS: Data were collected from 270 adult patients using the Revised Humane Caring Scale. Patients were moderately satisfied with the nursing care. There were significant differences of patients' level of satisfaction between/among socio-demographic subgroups including ethnicity, gender, reasons for admission and disciplines. Chinese patients were least satisfied with nursing care. The patients were most satisfied with 'Respecting patient's feeling' (mean=82.29, SD=14.50) and least satisfied with 'Communication and participation' (mean=62.00, SD=16.46). CONCLUSION: Our results reinforced the need to pay more attention to patient information provision and effective communication, which could improve patient satisfaction. The multi-ethnic patients valued respect as an influential attribute in quality nursing care.

Confirming nasogastric tube placement: Is the colorimeter as sensitive and specific as X-ray? A diagnostic accuracy study.

BACKGROUND: The effect of delivering enteral nutrition or medications via a nasogastric tube that is inadvertently located in the tracheobronchial tract can cause respiratory complications. Although radiographic examination is accepted as the gold standard for confirming the position of patients' enteral tubes, it is costly, involves risks of radiation, and is not failsafe. Studies using carbon dioxide sensors to detect inadvertent nasogastric tube placements have been conducted in intensive care settings. However, none involved patients in general wards. OBJECTIVE: The objective of this study was to ascertain the diagnostic measure of colorimeter, with radiographic examination as the reference standard, to confirm the location of nasogastric tubes in patients. DESIGN: A prospective observational study of a diagnostic test. SETTING: This study was conducted in the general wards of an approximately 1100-bed acute care tertiary hospital of an Academic Medical Center in Singapore. PARTICIPANTS: Adult patients with nasogastric tubes admitted to the general wards were recruited into the study. METHODS: The colorimeter was attached to the nasogastric tube to detect for the presence of carbon dioxide, suggestive of a tracheobronchial placement. The exact location of the nasogastric tube was subsequently confirmed by a radiographic examination. RESULTS: A total of 192 tests were undertaken. The colorimeter detected carbon dioxide in 29 tested nasogastric tubes, of which radiographic examination confirmed that four tubes were located in the tracheobronchial tract. The colorimeter failed to detect carbon dioxide in one nasogastric tube that was located in the tracheobronchial tract, thus, demonstrating a sensitivity of 0.80 [95% CI (0.376, 0.964)]. The colorimeter detected absence of carbon dioxide in 163 tested nasogastric tubes in which radiographic examination confirmed 160 gastrointestinal and one tracheobronchial placements, demonstrating a specificity of 0.865 [95% CI (0.808, 0.907)]. The colorimeter detected one tracheobronchial nasogastric tube placement that the radiographic examination was misinterpreted. CONCLUSION: The study found that the use of the colorimeter in the general ward setting was not 100% sensitive or specific in ascertaining the location of a nasogastric tube as previously reported by many studies undertaken in intensive care settings. This is the first study on the use of a colorimeter to confirm the placement of a nasogastric tube in adult patients in the general ward setting. More research on the use of a colorimeter in the general ward setting and its potential use in certain processes for confirming the placement of a nasogastric tube is warranted.

Total knee replacement pre-operative education in a Singapore tertiary hospital: A best practice implementation project.

OBJECTIVES: To increase the competency of specialist outpatient clinic nurses in the provision of pre-operative total knee replacement (TKR) education, and ensure that all patients scheduled for elective TKR received the pre-operative education package. METHODS: The project was implemented in three phases. Phase 1 entailed a baseline audit that analysed 30 randomized TKR patients who received pre-operative education. In Phase 2, the gaps and barriers in the project were discussed. Using best practice recommendations from the Joanna Briggs Institute, the project team leader collated and standardized the pre-operative education tools, which consisted of a pictorial booklet, a video and home care advice. A teaching plan guided the nurses to increase their understanding and improve practice using the education tools. The usefulness of education strategies and tools was discussed and these were improved over the proposed timeline. Phase 3 entailed a post-implementation audit to evaluate the provision of pre-operative education. RESULTS: Post implementation, nurses' competency in the provision of pre-operative TKR education increased from 18% to 91%. The number of patients who received the structured pre-operative education package increased from 27% to 50%. CONCLUSION: Overall, there was improvement in the provision of pre-operative TKR education to patients by clinic nurses using evidence-based best practice and a standardized education package.

Psychometric testing of the Revised Humane Caring Scale for adult patients in Singapore.

In this study, we examined the validity and reliability of the Revised Humane Caring Scale as used by adult patients in a tertiary hospital in Singapore. A three-phase descriptive quantitative study was conducted. In phase I, an expert panel of nurses and inpatients examined the content validity of the scale; phase II comprised a pilot study on 20 patients; and in phase III, a large-scale study on 235 patients was implemented to test the internal consistency of the scale. The results revealed that the content validity index of the scale ranged from 0.856 to 1, and the scale had a high inter-rater agreement kappa value of 0.940. Cronbach's alpha ranged from 0.798 to 0.877 in phase II, and from 0.579 to 0.760 in phase III, respectively. The Revised Humane Caring Scale revealed good content validity and an acceptable level of internal consistency. The scale is an acceptable measurement tool for evaluating adult patients' satisfaction during hospitalization.