Determination of service key performance indicators for emergency departments of teaching hospitals in Malaysia: A fuzzy delphi method.

INTRODUCTION: The most crucial step in forming a set of key performance indicators (KPI) for emergency department's (ED) staff is deciding the appropriate items for the KPI. This article demonstrates Fuzzy Delphi Method (FDM) as a scientific approach to consolidate consensus agreement within a panel of experts pertaining to each service related KPI item's appropriateness for ED. We aimed to develop framework of service key performance indicators for emergency departments of tertiary centres by using FDM. MATERIALS AND METHODS: The panel consists of ten experts from ED that was randomly chosen from list of specialists obtained from the National Specialist Registry for Emergency Medicine. A set of questionnaires that contains item constructs related to KPI based on structure, outcome and process was developed from initial literature search from Pubmed Central, Google Scholar, Cochrane Database and Public Library of Sciences. The construct then used for FDM session in second phase of the study. In FDM phase, the experts will rank each of the items created from nominal group technique (NGT) session by using Likert Scale ranged from 1 to 5 ("1" totally disagree and "5" extremely agree). FDM prerequisite must include threshold value (d) ≤0.2, expert consensus of >75% and average fuzzy numbers ("A" value) of >0.5. RESULTS: The initial item construct has produced 22 items proposed for the service KPI. Post FDM analysis for service KPI, 16 out of the 22 (72%) satisfied first prerequisite "d" value ≤0.2. For the second prerequisite, ten items (45%) from service KPI domain had expert consensus of more than 75%. For the third prerequisite, 16 out of the 22 (73%) fit the criteria of average fuzzy number ("A" value) of more than 0.5. In final model of FDM, 13 items (59%) were discarded and the remaining (n=9 items) that fulfilled all three prerequisites were retained for the final draft for content validation process. CONCLUSION: This study introduces that FDM can be used to obtain experts' opinion and consensus in order to achieve a decision. The experts' consensus on the suitability of the pre-selected items on the KPI set were obtained, hence it is now ready for further applicability in the clinical setting in ED.

A Survey on the Choice of Transportation to come to Emergency Department among Patients with Acute Coronary Syndrome of A Community in Malaysia.

BACKGROUND: Good coronary care begins from the patient's home, including early transportation. As such, it is recommended that the patients activate ambulances, rather than to use their own transportations to reach the hospitals. It is not known whether Malaysian patients prefer to use private transportations or ambulances when they develop chest pain. OBJECTIVES: This study is conducted to explore the question of the choice of transportation modes among patients with acute coronary syndrome and the reasons behind their choices. METHODS: This is a structured interview survey on patients diagnosed with acute coronary syndrome (ACS) in emergency department of Hospital Universiti Sains Malaysia from April 2012 to September 2012. RESULTS: Out of the 110 patients surveyed, 105 (95.5%) patients chose to use own transportation when they developed symptoms suggestive of ACS. Only 3 patients (2.7%) came to the emergency department within 1 hour of onset, and all these 3 patients chose to use ambulances as their modes of transportation. None of the patients who chose own transportation came within the first hour of symptoms onset. This is shown to be statistically significant (p<0.001). The level of education as well as past history of ischemic heart disease did not significantly influence the patients' choice of transportation. CONCLUSION: The admonishment by various international resuscitation councils that patients with chest pain should be transported via ambulances may not be as straightforward as it seems. Numerous local and regional socio-cultural and logistic factors may need to be addressed.

Knowledge of Good Blood Culture Sampling Practice among Healthcare Staffs in An Emergency Department - Are We Getting It Right?

BACKGROUND: Although a vital test, blood culture is often plagued with the problem of contamination and false results, especially in a chaotic emergency department setting. The objectives of this pilot study is to find out the level of understanding among healthcare staffs in emergency department, Hospital Universiti Sains Malaysia (HUSM) regarding good blood culture sampling practice. METHODS: All healthcare staffs in emergency department, HUSM who consented to this study were given a set of selfadministered anonymous questionnaire to fill. RESULTS: More than half (53.1%) of the 64 participants are emergency medicine residents. Majority of them (75%) have been working in the emergency medicine, HUSM for more than 2 years. More than half of them were able to answer correctly the amount of blood volume needed for culture in adult and pediatric patients. When asked what are the factors required to improve the true yield as well as to reduce the risk of culture contamination, the four commonest answers given were observing proper aseptic technique during blood sampling, donning sterile glove, proper hand scrubbing as well as ensuring the sterility of the equipments. DISCUSSION AND CONCLUSION: This study suggests that there is a lack of proper knowledge of good blood culture sampling practice among our healthcare staffs in emergency department.

Ultrasonography measurement of inferior vena cava diameter of blood donors as predictors for early blood loss in tertiary hospital northeastern, malaysia.

According to the class of hypovolaemic shock, a blood loss less than 750 ml is not associated with the physiological changes. As a result it may cause a delay in fluid resuscitation. We postulate inferior vena cava (IVC) diameter reduction in inspiration and expiration may resemble the significant volume of blood loss in a healthy adult. We conducted a study to examine the changes of the IVC diameter pre and post blood donation.The inferior vena cava diameter during inspiration (IVCi) and expiration (IVCe) were measured using ultrasound (GE HEALTH) in supine position before and after blood donation of 450 ml. Paired t-test and Wilcoxin rank test were used to analyse the data. Forty two blood donors enrolled during the study period. The mean age of blood donors was 32.3 +/- 8.9 and mainly male blood donors. The mean IVCe of pre and post blood donation was 18.5 +/- 6.2 mm (95%CI 18.23, 18.74) and 16.6 +/- 6.6 mm (95%CI 16.35, 16.76) respectively. Meanwhile, the mean IVCi of pre and post blood donation was 17.1 +/- 8.6 mm (95%CI 16.89,17.30) and 15.6 +/- 6.6 mm (95%CI 15.43,15.81) respectively. The mean difference of IVCe pre and post blood donation was 1.9 +/- 0.5 mm (95%CI 1.75, 2.13) (p<0.001). In contrast, the mean difference of IVCi pre and post blood donation was 1.5 +/- 0.5 mm (95%CI 1.34, 1.68) (p<0.001). As a conclusion, the measurement of IVC diameter by ultrasound can predict the volume of blood loss in simulated type 1 hypovolaemia patient.

Ultrasonography measurement of inferior vena cava diameter of blood donors as predictors for early blood loss in tertiary hospital northeastern, malaysia

According to the class of hypovolaemic shock, a blood loss less than 750 ml is not associated with the physiological changes. As a result it may cause a delay in fluid resuscitation. We postulate inferior vena cava (IVC) diameter reduction in inspiration and expiration may resemble the significant volume of blood loss in a healthy adult. We conducted a study to examine the changes of the IVC diameter pre and post blood donation.The inferior vena cava diameter during inspiration (IVCi) and expiration (IVCe) were measured using ultrasound (GE HEALTH) in supine position before and after blood donation of 450 ml. Paired t-test and Wilcoxin rank test were used to analyse the data. Forty two blood donors enrolled during the study period. The mean age of blood donors was 32.3 +/- 8.9 and mainly male blood donors. The mean IVCe of pre and post blood donation was 18.5 +/- 6.2 mm (95%CI 18.23, 18.74) and 16.6 +/- 6.6 mm (95%CI 16.35, 16.76) respectively. Meanwhile, the mean IVCi of pre and post blood donation was 17.1 +/- 8.6 mm (95%CI 16.89,17.30) and 15.6 +/- 6.6 mm (95%CI 15.43,15.81) respectively. The mean difference of IVCe pre and post blood donation was 1.9 +/- 0.5 mm (95%CI 1.75, 2.13) (p<0.001). In contrast, the mean difference of IVCi pre and post blood donation was 1.5 +/- 0.5 mm (95%CI 1.34, 1.68) (p<0.001). As a conclusion, the measurement of IVC diameter by ultrasound can predict the volume of blood loss in simulated type 1 hypovolaemia patient.

A Survey on The Knowledge, Attitude and Confidence Level of Adult Cardiopulmonary Resuscitation Among Junior Doctors in Hospital Universiti Sains Malaysia and Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia.

Junior doctors are often the "first line" doctors called to attend to patients in cardiac arrest. We performed an anonymous questionnaire study from October 2008 to December 2008 to assess the knowledge, attitude and skill of cardiopulmonary resuscitation among junior doctors in Hospital Universiti Sains Malaysia and Hospital Raja Perempuan Zainab II. Out of the 100 questionnaire forms sent out, 70 were returned completed. The majority (85.8%) stated that they were not confident of managing a resuscitation case. There was a statistically significant (p<0.001) association between duration of clinical practice and confidence level. Up to 77.1% said that BLS should be re-certified every two years.

An eight-year review of blood culture and susceptibility among sepsis cases in an emergency department in Northeastern Malaysia.

An understanding of common pathogens and their antibiotic sensitivity patterns is critical for proper management of sepsis in Emergency Department (ED). The goal of the study was to identify common organisms isolated from blood cultures of patients attended to ED and their antimicrobial susceptibility. Beginning from 2002, all cases of positive blood culture collected by the ED, Hospital Universiti Sains Malaysia (HUSM) were recorded and analysed. Over the period of eight years, we documented 995 cases of positive blood cultures. Of these samples, 549 (55.2%) were Gram-negative bacteria; 419 (42.1%) were Gram-positive bacteria; 10 (1.0%) were anaerobic organisms; 10 (1.0%) were fungus; and 7 (0.7%) cases were mixed organisms. Gram-negative bacteria were observed to develop more resistance to antimicrobial agents, especially those commonly used in an outpatient setting with less than 80% sensitivity to ampicillin, cotrimoxazole and ciprofloxacin. By contrast, there has been no marked change in the sensitivity trends of Gram-positive bacteria over the same period. In conclusion, ED physicians are more equipped to initiate empirical antimicrobial therapy especially when dealing with possibility of Gram-negative sepsis.

An eight-year review of blood culture and susceptibility among sepsis cases in an emergency department in North eastern Malaysia

An understanding of common pathogens and their antibiotic sensitivity patterns is critical for proper management of sepsis in Emergency Department (ED). The goal of the study was to identify common organisms isolated from blood cultures of patients attended to ED and their antimicrobial susceptibility. Beginning from 2002, all cases of positive blood culture collected by the ED, Hospital Universiti Sains Malaysia (HUSM) were recorded and analysed. Over the period of eight years, we documented 995 cases of positive blood cultures. Of these samples, 549 (55.2%) were Gram-negative bacteria; 419 (42.1%) were Gram-positive bacteria; 10 (1.0%) were anaerobic organisms; 10 (1.0%) were fungus; and 7 (0.7%) cases were mixed organisms. Gram-negative bacteria were observed to develop more resistance to antimicrobial agents, especially those commonly used in an outpatient setting with less than 80% sensitivity to ampicillin, cotrimoxazole and ciprofloxacin. By contrast, there has been no marked change in the sensitivity trends of Gram-positive bacteria over the same period. In conclusion, ED physicians are more equipped to initiate empirical antimicrobial therapy especially when dealing with possibility of Gram-negative sepsis.