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KPJ Healthcare Berhad (247079-M)

(A member of Johor Corporation Group)

Volume 4 • Number 1 • January

KPJ MedicalJOURNAL2010

Editor : Azizi Haji Omar

Co-Editor : Zainudin Md Zin

Editorial Board : Abdul Malik Mohamed HusseinAminuddin SaimGunasegaran P.T.RajanMohd Daud Sulaiman Navinbhai PatelNoor Hisham Mansor

Assistant Editors : Anitha K.V.Esther WooFatimatul Masri Hj Dzulkifli

Publisher : KPJ Healthcare Berhad (247079-M)

7, Pesiaran Titiwangsa 3,53200, Kuala LumpurTel: (603) 4022 6222Fax: (603) 4022 7237Email: kpj@kpjhealth.com.myWebsite: www.kpjhealth.com.my

Copyright©2010 by KPJ. All rights reserved.

Reproduction in whole or in part without prior permission is prohibited.

KPJ MedicalJOURNALKPJ Healthcare Berhad (247079-M)(A Member of Johor Corporation Group)

The publisher and editor are not responsible for views expressed bycontributors. The inclusion of product advertisements in this Journal doesnot imply endorsement by the publisher and editor of these products.

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Volume 4 • Number 1 • January 2010

KPJ MedicalJOURNALiv From The Editor

INVITED COMMENTARY

1 Building A Safety and Quality CultureAbu Bakar Suleiman

QUALITY AND SAFETY IN PATIENT CARE

8 Sharing Experience: Improving Hand Hygiene to Prevent Healthcare AssociatedInfections

Sahrul Bariyah Bt Sanat,Khoo Gaik Eng,Norkhairiah Sudin and Asmida Sabirin

14 Reducing Risk of Patient Harm Resulting From FallsMaygala A.,Primuhasa Putra SHA,Aziz AR,Suzana K,Ainol MR,Zainab MN,Jaliah MJ,Halimaton DY and Sumaria AM

20 A System Approach to the Reduction of Medication Administration Error Among NursesZaharah Osman

23 The Pathway for Home Mechanical Ventilation (HMV)Nur Yasmin Jennifer Abdullah and Richard Lobo

CASE REPORTS

27 A Case of Idiopathic Thrombotic Thrombotycopaenic Purpura Successfully Treated withTherapeutic Plasma Exchange

Goh Kim Yen

29 Peripheral Blood Stem Cell Transplant Procedure for Acute Myeloid Leukaemia inComplete Remission in KPJ Ampang Puteri Specialist Hospital

Goh Kim Yen

31 Unicentric Castleman’s Disease of the ParotidGopalan KN,Primuharsa Putra SHA,Marina MB,Mazita A and Valuyeetham KA

33 Cat-scratch Disease Presenting as Parotid MassPrimuharsa Putra SHA,Marina MB,Razif MY and Tang MK

35 Platysma Flap in Oral Cavity ReconstructionPrimuharsa Putra SHA,Marina MB,Roszalina R and Ridzo Mahmud

37 Fever of Unknown Origin:Consider Adult Onset Still’s DiseaseRamanathan M

ANNOTATIONS

41 The Novel Influenza A (H1N1) Infection in Infants and ChildrenMusa Mohd.Nordin

44 Vaccines – Protection for LifeMusa Mohd.Nordin and Zulkifli Ismail

46 Introduction to the Casemix Groups – Diagnosis Related Groups (DRG)Zafar Ahmed

CLINICAL IMAGES

48 Radiological Quiz:A 20 Month Old Girl with Fever and IrritabilityNurhayati Mokhty

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In this issue of the Journal a special emphasis is given to issuesrelated to quality and safety in patient care. The Group hasadopted seven safety goals and workshops have been conducted toimplement policies related to these goals. We have now joinedmany others worldwide in a movement to ensure quality andsafety for our patients as a prerequisite to care. However, as manyhave found over the past ten years, issues involving quality andsafety are complex ones. Success requires an intrinsic willingnessamong all health care professionals to change. Teamwork isessential. Champions have to be identified to effect changes inattitudes and practices. A safety culture has to be established andconstantly monitored.

Tan Sri Abu Bakar Suleiman addresses some of the basic issues ofsafety in patient care and his commentary provides us with aframework for initial work in our setting. The following fourarticles are early examples of work that can be done to addresslocal problems. More sophisticated work will be produced in thefuture as momentum gathers. We look forward to seeing researchin safety and quality as the main thrust in our renewed interest inresearch and development.

Azizi Haji Omar, FRCP, FAMM

FROM THE EDITOR

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KPJ Medical Journal 4:1–7 (2010) 1

Building A Safety and Quality Culture

Abu Bakar Suleiman*

INVITED COMMENTARY

Medicine and healthcare have made enormousprogress as a result of the advances in science andtechnology over the last century. However, we are facedwith major challenges in ensuring that healthcareservices are delivered safely and according to the needsand expectations of the patients. The great emphasis onscience and technology in the development of modernmedicine with the tendency of depersonalising healthcare services received by patients, had given rise towidespread concern, that an International Consultationon the future direction of Medicine was organized byThe Hastings Centre, New York. The report of thisConsultation included a reiteration of The Goals ofMedicine (refer Fig. 1), which they believe can be a basisfor the direction that Medicine should take for the future.They also believe that these Goals can be the basis toguide the development of health research and of medicaleducation.1

While healthcare has made remarkable improvements,the healthcare industry has faced numerous and severecriticisms over alleged shortcomings: the rapidly risingcost of healthcare, with no end in sight, long waitingperiods for service; the allegedly high error rate; andeven evidence of greed and fraud in some sectors of theindustry.2 The concern that healthcare can and shouldlearn from other industries in quality improvementexperience led to the National Demonstration Project(NDP) in the USA: the pairing of 21 health careorganizations, each of them new to quality improvement,with an equal number of experts on quality control and improvement in other industries who served asmentors. This project was led by Don Berwick fromHarvard Medical School, and the report of this project,CURING HEALTH CARE, New Strategies for QualityImprovement, published in 1990, is valuable to those inthe healthcare industry who wish to achieve long-lastingsuccess.3

*Tan Sri Dato’Dr Abu Bakar SuleimanPresident, International Medical University, Kuala Lumpur

Chairman, Medical Advisory Committee,KPJ Healthcare Berhad

Fig.1. The Hasting Center Report, The Hastings Center, New York, Nov/Dec 1996

● The prevention of disease and injury and the promotion andmaintenance of health

● The relief of pain and suffering caused by maladies

● The care and cure of those with a malady, and the care ofthose who cannot be cured

● The avoidance of premature death and the pursuit of apeaceful death

“The Goals of Medicine:Setting New Priorities”,

proposed four goals

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2 Abu Bakar Suleiman

QUALITY AND SAFETY IN HEALTHCARE

The issues of quality and safety in health care havereceived widespread attention, especially in the last twodecades when numerous publications in the scientificand the lay media have focused on these topics. A lot ofresearch had been done on practice variation, health carequality and patient safety from the 1950’s to the 1990’s.An important group working on health care quality is theInstitute of Medicine’s Roundtable on Health CareQuality, which made an important report in 1998,4 whichsaid:

“Serious and widespread problems existthroughout American medicine. The problems occurin small and large communities alike, in all parts ofthe country, and with equal frequency in managedcare and fee for service systems of care. Very largenumbers of Americans are harmed as a result.Quality of care is the problem, not managed care.Current efforts to improve will not succeed unlesswe undertake a major systemic effort to overhaulhow we deliver health care services, educate andtrain clinicians, and assess and improve quality.”The Roundtable classified the pervasive quality

problems in to three types:● OVERUSE of procedures and interventions that

cannot, on scientific grounds, help the patients whoget them – such as 20 percent to 50 percent of moreunnecessary surgery rates for specific procedures,and 30 percent or more overuse of powerfulantibiotics

● UNDERUSE of treatments and interventions thatare known scientifically to be helpful to patients –such as omitting effective vaccines for half of theelderly people in the United States, or failing to uselife-extending treatments in half of our heart attackvictims

● MISUSE, which refers to errors in execution ofcare – mistakes and slip-ups that don’t quite fit intothe overuse and underuse categories, such asserious medication errors in seven out of onehundred hospital patients

Interest in quality and patient safety in health carehave also been seen in the lay media, and MichaelMillensen, a three times Pulitzer Prize nominatedjournalist from the Chicago Tribune have taken anenlightened and provocative look at the state of qualityimprovement in medicine and the health care system inthe USA.5 He raised numerous issues regarding qualityin health care, and his book would be of benefit topatients, doctors and policy makers alike. He observesthat "the idea that medical treatment can be measuredand managed still makes many physicians and non-physicians alike, deeply uncomfortable. It calls intoquestion many of our assumptions about the mixture ofart and science that goes into medicine. It requires arethinking of physician professionalism and of theresponsibility of patients".6

PRACTICE VARIATION IN MEDICINE

Millensen cited the work of Wennberg at theUniversity Hospital in Burlington, USA and at theUniversity of Vermont, School of Medicine. Wennberg’sresearch on practice variation was received ratherunhappily by the Medical School that they requested thefederal government to audit Wennberg’s work forviolation of rules. The auditors however praisedWennberg’s work instead, but the Medical Schoolauthorities still advised Wennberg to find workelsewhere. One of the federal auditors helped Wennbergto obtain a job at Harvard, where with John Bunker, aprofessor of Anesthesiology and pioneer health servicesresearcher, Wennberg co-edited an editorial in the 6 December 1973 issue of the New England Journal ofMedicine on practice variation. This accompanied anarticle in the journal documenting different rates ofsurgery in Canada and the USA. In the editorial "the twodoctors virtually accused fellow American physicians ofkilling patients with unnecessary procedures".

Wennberg’s subsequent work looking at the scientificbasis of medical practice got the attention of policy-makers and the public, and even the popular press. Hiswork helped to create an intellectual climate for moreother work to be done on practice variation and on theemphasis and the importance of health outcomesresearch. In fact a lot of work on health services researchhad been done in the 1950’s and 1960’s, howeverWennberg’s work in the 1970’s and 1980’s,brought it tothe attention of policy-makers and the public in the USA.7

Wennberg’s early experience when his research wasnot well received by his Medical School has a familiarring. This had occurred to so many prominent doctors, ifwe are to look at the history of medicine. Ignaz PhillipeSemmelweis (1818–1865) working at the ObstetricClinic at the University of Vienna, demonstrated theimportance of hand-washing in reducing mortalityamong his obstetric patients. His colleagues were notimpressed with his findings, and he was in fact dismissedfrom his position. He was so concerned that the lives ofthousands of mothers would be sacrificed through theignorance and conservatism of his colleagues. Hepreached in favour of hand hygiene, but was not heeded,and was later confined to an asylum where, he ironicallydied of sepsis.8 Joseph Lister (1827–1912) worked onthe antiseptic principle, where he showed theeffectiveness of protecting open fractures from bacteriaby using carbolic acid, with very impressive results,which was published in 1867. Despite the impressiveresults, his methods were very slow to be accepted. Hismethods were eventually taken up and developed by theGermans in the 1870’s and later followed by the USA,France and eventually England.9

This pattern of conservatism and reticence to changeis often seen in the history of medicine, and notconsistent with our modern emphasis on evidence-basedmedicine. However it needs to be understood and taken

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Building A Safety and Quality Culture 3

account of, in the management of change process, ifchange is to successfully occur in implementing newideas or discoveries.

HOW HEALTH CARE ORGANISATIONS DEALWITH MAJOR FAILURES

Walshe and Shortell10 studied major failures, whichwas defined as breakdowns in health care services orprovision that do substantial harm to many patients, fromsix countries (The United States, the United Kingdom,Australia, New Zealand, Canada, and the Netherlands).They studied how health care systems and organisationsdeal with these failures.

Some common themes run through many of theinstances of major failures identified and across thecountries studied by Walshe and Shortell:

● Longstanding problems – these failures have oftenbeen present and known about for years or evendecades before they are brought to light. Examplesinclude the case of Harold Shipment in Englandwho murdered more than 200 patients duringtwenty-three years in general practice, and the caseof surgeon Robert Brewer who continued inpractice in Virginia for more than a decade, despitegross errors and startling instances ofincompetence that were known about by thehospital where he worked.

● Well known problems, but not handled – keypeople and stakeholders knew something wasseriously wrong and did nothing about it. In theBristol Royal Infirmary case, poor clinicalpractices and outcomes in pediatric cardiac surgerywere well known within the hospital, and amongprofessional leaders in the Royal College ofSurgeons and civil servants at the Department ofHealth. Similar behavior was observed in a similarfailure in pediatric cardiac surgery in Winnipeg,Manitoba, in 1994. In the case of Redding MedicalCentre in California, physicians did large volumesof inappropriate and unnecessary procedures onlargely healthy patients, and many hospital staffwere aware of what was going on. It appeared oftenthe only people who did not know about theproblems were the unsuspecting patients and theirfamilies.

● Cause of Immense Harm – these failures causeimmense harm, for example failures in the bloodservice in Canada caused injury to 30,000 patients.

● Lack of Management systems – failures oftenhappened in dysfunctional organizations, wherefundamental management systems for qualityreview, incident reporting, and performancemanagement are lacking, or if present are easilybypassed. There is frequently little collaborationbetween managers and clinicians and a lack ofcoherent clinical leadership.

● Repeated Incidents – some failures occurrepeatedly, suggesting that lessons are not beinglearned. Health care organizations have beencomplacent in the face of outright evidence thatpatients were being harmed, slow to suspectwrongdoing, and reluctant to address the problem.

BARRIERS TO DISCLOSURE AND INVESTIGATION

Major failures appear difficult to expose andinvestigate and it is striking they are not exposed bysystems for quality assurance or improvement, clinicalaudit, risk management, and external arrangements forregulation, accreditation, and oversight. Walshe andShortell observed numerous barriers to disclosure andalso barriers to reform. They believed that major failuresin health care are a product of the distinctive culture ofthe organizations, the health care professions, and thehealth system, and is an issue of great internationalconcern with the endemic secrecy, deference toauthority, defensiveness, and protectionism.

PATIENT SAFETY

A lot of research had been done on practice variation,health care quality and patient safety since the 1950’s,however the focus on patient safety had the biggestimpact on doctors, policy makers and the public after thepublication of a report on "The Quality of Health Care inAmerica project" published by the Institute of Medicine,USA in 1999, which addressed the serious issue ofpatient safety in the delivery of health care.11 This reportwas based on the study of research previously done onpractice variation, health care quality and patient safety.It pointed out that at least 44,000 Americans died eachyear as a result of medical errors, making it the 8thleading cause of death, exceeding those dying frommotor vehicle accidents, breast cancer or AIDS.Medication errors alone are estimated to account for7000 deaths annually.12

The IOM’s first report in 1999 "To Err is Human:Building a Safer Health System" recommended acomprehensive approach to improving patient safety, asthere is no single solution to solve the problem. Therecommendations were set out a four tiered approach:13

● Establishing a national focus to create leadership,research, tools and protocols to enhance theknowledge base about safety,

● Identifying and learning from errors throughimmediate and strong mandatory reporting efforts,as well as encouragement of voluntary efforts, bothwith the aim of making the system continue to bemade safer for patients,

● Raising standards and expectations for improvementsin safety through oversight organizations, grouppurchasers and professional groups, and

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4 Abu Bakar Suleiman

● Creating safety systems inside health careorganizations through the implementation of safepractices at the delivery level. (ultimate target ofthe recommendations )

While the IOM report in 1999 focused on PatientSafety with a call to action to make care safer, the IOMreport in 2001 covered broader quality issues, with a callto action to improve the American health care deliverysystem as a whole in all quality dimensions.14 This reportentitled "Crossing the Quality Chasm: A new healthsystem for the 21st Century" observed that, the currenthealth care system cannot do the job of achieving ahealth care system of quality that Americans need, wantand deserve. Trying harder will not work, changingsystems of care will. Safety and quality problems inhealth care are the result of outmoded systems of work.To have safer, higher quality care, we will need to haveredesigned systems of care, including the use ofinformation technology to support clinical andadministrative processes. The report has proposed aspecific agenda for redesigning the 21st Century healthcare system14 and proposes six aims for improvements.Health care should be:

● Safe – avoiding injuries to patients from the carethat is intended to help them

● Effective – providing services based on scientificknowledge to all who could benefit and refrainingfrom providing services to those not likely tobenefit (avoiding underuse and overuse,respectively)

● Patient Centred – providing care that is respectfuland responsive to individual patient preferencesand values and ensuring that patient values guideall clinical decisions

● Timely – reducing waits and sometimes harmfuldelays for both those who receive and those whogive care

● Efficient – avoiding waste, including wastemanagement, supplies, ideas and energy

● Equitable – providing care that does not vary inquality because of personal characteristics such asgender, ethnicity, geographic location andsocioeconomic status

A health care system that have achievedimprovements in the above six dimensions would be farbetter at meeting patient’s needs. Patients would receivecare that would be safer, more reliable, more responsive,more integrated and more available. Patients can receivepreventive, acute and chronic services, from which theyare likely to benefit. In such a system, clinicians wouldexperience the satisfaction of providing care that wouldbe more reliable, more responsive to patients and morecoordinated than is the case today.

WORLD HEALTH ORGANISATION’S (WHO)RESPONSE TO CALL FOR ACTION ON PATIENTSAFETY

In May 2002, the 55th World Health Assemblyadopted WHA resolution 55.18, which urged memberstates to improve patient safety and quality of health care.

In May 2004, the 57th World Health Assemblysupported the creation of an international alliance tofacilitate the development of patient safety policy andpractice in all member states, and to be a major force forimprovement internationally.15 The World Alliance forPatient Safety aims to fulfill WHA resolution 55.18

Through concerted effort in key priority areas, the World Alliance for Patient Safety aims to:-

● Support the efforts of Member States to promote a culture of safety within their health-care systemsand develop mechanisms to enhance patient safety;

● Put patients at the heart of the international patient safety movement;

● Catalyse political commitment and global action on areas on greatest risk to patient safety through theGlobal Patient Safety Challenge;

● Develop global norms, standards and guidelines for ways of detecting and learning from patient safetyproblems to reduce risks for future patients;

● Make safety solutions widely available to all Member States in ways which are as easy as possible toimplement and relevant to their needs;

● Develop and spread knowledge about evidence-based policies and best practices in patient safety;

● Build consensus on common concepts and definitions of patient safety and adverse events;

● Initiate and foster research in areas which will have most impact on safety problems;

● Explore ways in which new technologies such as simulation methods can be harnessed in the interestof safer care;

● Bring together partners to contribute towards knowledge development and social mobilization;

● Target technical work to reflect the patient safety priorities both of developed and developing countries.

Fig. 2. Forward Programme 2006-2007 World Alliance For Patient Safety. World Health Organisation, 2006

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Building A Safety and Quality Culture 5

through "international leadership and by creating anover-arching strategy, action programmes and a coalitionof nations, stakeholders and individuals to transform thesafety of health care worldwide". Their ForwardProgramme is shown in Fig. 2, and their Action Areas2006-2007 is as shown in Fig. 3.

Malaysia has supported the activities of the Worldalliance for Patient Safety, and has formed The NationalPatient Safety Council, which is working on developingand implementing the national patient safety goals forthe country, based on recommendations of the WorldAlliance for Patient Safety. The Kumpulan PerubatanJohor (KPJ) network of hospitals has adopted and isstarting to initiate their own KPJ patient safety goals.This is being built on the framework of the qualityassurance and improvement, incident reporting andclinical risk management that already exists in the KPJmanagement system.

CLINICAL GOVERNANCE IN KPJ HOSPITALS

Clinical Governance in the KPJ network of hospitalshas been implemented over the last seven years, and isbased on the concept and principles of ClinicalGovernance in the National Health Scheme (NHS) in theUnited Kingdom.16, 17 Clinical governance has beencited16 to be defined as "the framework through whichNHS organizations are accountable for continuouslyimproving the quality of their services and safeguardinghigh standards of care by creating an environment inwhich clinical care will flourish". It comprises thefollowing broad areas of processes:

● Clear lines of responsibility and accountability forthe overall quality of clinical care

● A programme of quality improvement activities● Clear policies aimed at managing risk● Procedures for all professional groups to identify

and remedy poor performance

Action area 1 The Global Patient Safety Challenge will galvanize global commitment and actionon a patient safety topic which addresses a significant area of risk for all MemberStates.

In 2005-2006, the Global Patient Safety Challenge is focusing on health care-associated infection with the theme Clean Care is Safer Care.

For 2007-2008, the Global Patient Safety Challenge will focus on the topic of safersurgery with the theme Safe Surgery Saves Lives.

Action area 2 Patients for Patient Safety will ensure that the voice of patients is at the core of thepatient safety movement worldwide.

Action area 3 Reporting and Learning will promote valid reporting, analytical and investigativetools and approaches that identify sources and causes of risks in a way that promoteslearning and preventive action.

Action area 4 Taxonomy for Patient Safety will develop an internationally acceptable system forclassifying patient safety information to promote more effective international learning.

Action area 5 Research for Patient Safety will facilitate an international research agenda whichsupports safer health care in all WHO Member States.

Action area 6 Safety Solutions will translate knowledge into practical solutions and disseminatethese solutions internationally.

Action area 7 Safety in Action will spread best practices for implementation of changes inorganizational, team and clinical practices to improve patient safety.

Action area 8 Technology for Patient Safety will focus on the opportunities to harness newtechnologies to improve patient safety.

Action area 9 Care of acutely ill patients will identify key patient safety priorities for action in thecare of seriously ill patients.

Action area 10 Patient safety knowledge at your fingertips will work with Member States andpartners to gather and share knowledge on patient safety developments globally inthe form of a global report.

Fig. 3. Action Areas 2006-2007. World Alliance For Patient Safety, World Health Organisation, 2006

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6 Abu Bakar Suleiman

The components of clinical governance includestatutory duties, structure and accountability, processesand support as is shown in Fig. 4. Clinical governance ispart of Corporate Governance in KPJ and clinicalgovernance reports are regularly tabled at KPJ Board ofDirectors meetings. A systems approach to improvingpatient safety and quality in health care is essential, andshould be part of the management system of any healthcare organization, and be included in the structure ofclinical governance, and be under the direct oversight oftop management and the board of directors. An example

of the reporting infrastructure for clinical governance inhospitals is shown in Fig. 5.

The clinical governance committee is led by themedical director of the hospital, with representationfrom management and other clinical professionals. Themedical director is a member of the board of directors ofthe hospital. This approach in the model of clinicalgovernance, encourages teamwork and collaborativestandard setting, helps develop shared information tomonitor standards of care delivered. It also empowersand enables clinicians to take the lead to ensureaccountability for clinical services delivered.

Fig. 5. Example of reporting infrastructure in clinical governance

Fig. 4. Components of Clinical Governance from Thoreya Swage, “Clinical Governance inHealthcare Practice”. Butterworth Heinemann, Oxford, 2001, page 7

STATUTORY DUTIES Clinical governance as part of corporate governance

STRUCTURE AND Board, Chief Executive, clinical governance committeeACCOUNTABILITY

PROCESSES Quality improvement activities, risk management,professional performance and involvement of users

SUPPORT Workforce planning, information, management & technologyprofessional development – clinicians and managers

➝

➝

➝

➝

➝

➝

➝

➝

➝➝

➝

➝

Evidence Based Medicine,Clinical Practice Guidelines, etc

Clinical audit, clinical riskmanagement, complaints (clinical), etc

Board of Directors of Hospital

Hospital Management

Audit Committee Clinical Governance Committee

Setting of Policy Monitoring of Policy

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Building A Safety and Quality Culture 7

CONCLUSION

The concern about patient safety and improvingquality of health care has been rising around the world.Walshe and Shortell in their study of this in fivecountries had observed some common themes across thecountries studied, including barriers to disclosure andinvestigation, and barriers to reform.14 They noted that"despite much rhetoric about primacy of patient’sinterests, it seems that when it matters most, theseinterests are too often subordinated to the needs andinterests of health care organizations and professionals."These common themes observed by Walshe and Shortellmost likely apply to other countries, including Malaysia,and is indicative of the enormity of the task faced inimproving patient safety and healthcare quality in ourhealth system.

There is a great need to develop quality improvementin health care as a system property. Similarly patientsafety needs to be developed as a system quality andusing knowledge and experience in safety science to beapplied to health care services. The IOM report (2001),had proposed an ambitious, important and much neededagenda for redesigning the 21st – century health caresystem.13 It is very complex, and includes a new vision,new objectives, new rules to redesign health caredelivery, the practice of evidence based medicine,aligning payment policies with quality improvement andcontinuing professional development that is relevant toclinical practice and performance.

There is a need to create a more open, transparent,equitable and accountable health care culture. In sodoing, there should be greater emphasis on the goals ofmedicine as reiterated by the Hastings Centerconsultation,1 and the importance of patient safety andquality improvement in health care should beincorporated into the curriculum in medical and healthprofessions education, at undergraduate and graduatelevels. There need to be greater progress in themeasurement of clinical performance, reporting ofhealth care quality and patient outcome information.There must be greater demand for accountability fromhealth care organizations. There must also be morecoherent, principled and capable clinical and managerialleadership of health care organizations. The challenge isimmense, and clinicians have the opportunity to take theleadership role and participate in this process of change,which is occurring around the world. They can do this

particularly by championing the importance of qualityimprovement and patient safety in their respectivepractices and in healthcare delivery in their hospitals,and by ensuring the development of clinical governanceas part of corporate governance in their hospitals.

REFERENCES

1. The Goals of Medicine, The Hastings Center Report, TheHastings Center, New York, Nov/Dec 1996.

2. Juran M, (foreward), in Berwick DM, Godfrey AB, Roessner J.Curing Health Care, Jossey – Bass, San Francisco, 1990.

3. Berwick DM, Godfrey AB, Roessner J, Curing Health Care,Jossey – Bass, San Francisco,1990.

4. Chassin MR, Galvin RW. "The urgent need to improve HealthCare Quality": The Institute of Medicine Roundtable on HealthCare Quality, JAMA, 1998,280,(11),1000-1005.

5. Millensen ML Demanding Medical Excellence: Doctors andAccountability in the Information Age, University of ChicagoPress, Chicago,1997.

6. Millensen ML Demanding Medical Excellence: Doctors andAccountability in the Information Age, University of ChicagoPress, Chicago,1997., pg 12.

7. Millensen ML Demanding Medical Excellence: Doctors andAccountability in the Information Age, University of ChicagoPress, Chicago,1997., pg 45, 46.

8. Ackerknecht EH. A short history of medicine, The John HopkinsUniversity Press, Baltimore and London, 1982. Pg 187 – 188.

9. Ackerknecht EH. A short history of medicine, The John HopkinsUniversity Press, Baltimore and London, 1982. Pg 191.

10. Walshe K, Shortell SM. When Things Go Wrong: How HealthCare Organisations Deal With Major Failures. Health Aff., 2004,23(3): 103-111

11. Institute of Medicine. To Err Is Human: Building a Safer HealthSystem. Kohn LT, Corrigan JM, Donaldson MS, eds. Washington,D.C. National Academy Press,1999.

12. Institute of Medicine. To Err Is Human: Building a Safer HealthSystem. Kohn LT, Corrigan JM, Donaldson MS, eds. Washington,D.C. National Academy Press,1999, pg1

13. Institute of Medicine. To Err Is Human: Building a Safer HealthSystem. Kohn LT, Corrigan JM, Donaldson MS, eds. Washington,D.C. National Academy Press,1999, pg 6-15

14. Institute of Medicine. Crossing The Quality Chasm: A NewHealth System for the 21st Century: Committee on Quality ofHealth Care in America, Washington, D.C. National AcademyPress,2001

15. World Alliance for Patient Safety: Forward Programme, 2006-2007. World Health Organisation, 2006.

16. Swage,T. Clinical Governance in Health Care Practice.Butterworth – Heinemann, Oxford, 2000.

17. Lugon, M, Secker – Walker J. Clinical Governance: Making itHappen. Royal Society of Medicine Press, London, 1999.

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8 KPJ Medical Journal 4:8–13 (2010)

INTRODUCTION

Healthcare associated infections (HAIs) are infectionsacquired as a result of contact with the healthcare system in its widest sense - from care provided in thehome, to primary care, nursing home care and acute care in hospitals. Transmission of healthcare associatedpathogens most often occurs via the contaminated handsof healthcare workers.1

Hand hygiene is one of the most important proceduresfor preventing the spread of disease. We all know that,but in practice compliance with hand hygiene remainscapricious even in premier healthcare centers. Boyce andPittet indicate that "Hand hygiene has long beenconsidered one of the most important infection controlmeasures for preventing healthcare associatedinfections. Failure to perform appropriate hand hygieneis considered to be a leading cause of healthcareassociated infections and the spread of multi-resistantmicroorganisms and has been recognized as a significantfactor to outbreaks."2

Nurses and other healthcare workers are frequentlyreminded of the importance of hand hygiene inpreventing infections. In studies conducted between1980 and 2001, the Center for Disease Control andPrevention (CDC) found that "among all healthcareworkers, compliance with recommended hand-hygieneprocedures was poor, occurring an average of 40%".3

Concern related to the practices and compliance levelto hand hygiene does not rely on individual factors alone,

because of the complexity of the process of change, it isnot surprising that this solo intervention often fails.Therefore multi-disciplinary strategies are necessary.Success requires active participation from organizations,social support, networks and each individual healthcareworker. It is also recognized that these improvementscould not easily be achieved and that the system neededto be changed.4

The 2008 International Patient Safety Goalsdeveloped by the World Alliance for Patient Safety aredesigned to ensure that the organization’s goals are beingmet and provide succinct, prioritized information to helppromote healthcare safety across the organization.5 Inline with the Government’s goal to promote a culture ofsafety and quality, KPJ Healthcare Berhad agreed toadopt and implement these seven safety goals.

This paper describes the initial development,implementation and sharing of experience in developingthe Hand Hygiene policy at KPJ Damansara. A guidelinehas been developed as a quality improvement initiative,to help promote hand hygiene awareness byimplementing hospital wide programme with specificquality improvements that immediately benefit patientsand healthcare workers.

ABSTRACTThis paper describes the development and implementation of KPJ Patient Safety Goals. KPJ Damansara Specialist Hospital has been assigned to pilot the KPJ Patient Safety Goal 6:Improve Hand Hygiene to prevent Healthcare Associated Infection. It is required to continuouslyimprove the safety and quality of care provided to the patients, employees and public through theprovision of proper health care services and quality improvement activities that supportperformance improvement in health care organizations. KPJ Medical Journal 2010; 4:8–13

Key words : Patient’s safety, hand hygiene.

Sahrul Bariyah Bt Sanat, SRN, MSc, Khoo Gaik Eng, SRN, Bsc Hons,Norkhairiah Sudin, SRN, Bsc Hons, and Asmida Sabirin, SRN, Bsc Hons

Sharing Experience: Improving Hand Hygiene toPrevent Healthcare Associated Infections

QUALITY AND SAFETY IN PATIENT CARE

Correspondence: Sahrul Bariyah Bt Sanat,KPJ Damansara Specialist Hospital, 119, Jalan SS 20/10,Damansara Utama, 47400 Petaling Jaya, Selangor Darul Ehsan.

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Sharing Experience: Improving Hand Hygiene 9

LITERATURE REVIEW

Hands are the principle route by which cross infectionoccurs.6 Hand hygiene is the single most effectiveinfection-control behaviour that stops the spread ofinfection.7 There are a number of factors that appear toaffect healthcare workers' compliance with hand-hygiene guidelines. Studies have shown that eachindividual’s perception, motivation and complianceshow variations between professions. Nurses have ahigher compliance rate than doctors.8, 9 A study by Pittet et al10 noted that non-compliance was higherbefore high-risk procedures, while Jenner et al11 andPittet12 observed that full compliance with hand hygienewhen care activity posed a high risk of cross-infectionwas poor.

The exact nature of the compliance with hand-hygiene guidelines requires an understanding of whatmotivates such behaviour. For example, healthcareworkers are generally aware of recommendationsregarding hand hygiene but knowledge and education donot in themselves continuously motivate hand-hygienebehaviour.13 This is supported by Jenner et al whoshowed that rates of compliance with hand hygienediffer.11

AIM

This study's aim is to examine healthcare workers'compliance with hand hygiene and to develop a policy tobe adopted by all KPJ Hospitals with the objective toimprove practices through education and provision ofadequate hand hygiene facilities for employees, patientsand guests.

SAMPLE SETTING

The sample for this study was obtained from allnursing units. Five clinical areas were selected for ourpilot project, namely Intensive Care Unit, NeonatalIntensive Care Unit, Special Care Nursery, the AdultMedical Ward and a Consultant Clinic.

PROCEDUREWe collected information from the infection control

department regarding changes in hand hygiene policiesand procedures before and after publication of the HandHygiene Policy Guideline (HHPG); obtaineddocumentation regarding staff education, infectioncontrol policies and procedures, product usage andmulti-disciplinary meetings regarding hand hygiene andcollected data regarding rates of HAI within the nursingunits studied.

During our survey, we audited units from whichinfection rates were available, recorded common areas in

which hand hygiene products were available, observeddirectly staff hand hygiene practices in the units andadministered an anonymous survey to staff (ie,physicians, nurses, and any ancillary direct patient carestaff such as respiratory therapists) regarding theirawareness of the HHPG.

INSTRUMENTS AND MEASURES

Hand Hygiene Questionnaire implementation andcompliance measures

The Hand Hygiene Questionnaire Survey was used tointerview the nursing staff. It measured hand hygieneawareness and consisted of three parts: (1) the awarenessof hand hygiene within the hospital (eg, the extent towhich it had been discussed with staff, and whether ornot there were special sessions conducted to educatestaff about hand hygiene); (2) the presence of therecommended products in the clinical units (availabilityof hand hygiene products) and (3) staff attitudes andpractices of hand hygiene (hand washing or hand rub)(Appendix A).

We also collected data regarding factors that couldpotentially confound the relationship between handhygiene and infection rates, and policies or otherinfection control practices, and occurrence of outbreaks.

The Hand Hygiene Surveillance Form was used fordirect observation of hand hygiene behavior in thenursing units to assess the specific circumstances inwhich health care workers do or do not comply with theguidelines. On the tool, indications for hand hygienefrom the CDC Guideline were listed. While directlyobserving a patient care provider, the observer notedwhen one of the indications occurred and then whetherhand hygiene also occurred, either with soap and wateror with an alcohol-based product. From theseobservations, it was possible to calculate an overall handhygiene rate (number of hand hygiene episodes/numberof indications) as well as a proportion of hand hygiene.

RESULTS

We found that common barriers to staff members'compliance with hand hygiene guidelines were lack ofknowledge among personnel on the importance of handhygiene in reducing the spread of infection, lack ofunderstanding of correct hand hygiene technique, poorcompliance to policies and procedures, increasedworkload and activities, overcrowding, insufficient andpoor access to hand hygiene facilities and posters andlack of training. Our findings were similar to thosereported by healthcare workers in the US.9, 14

Hand Hygiene Guideline implementation and handhygiene compliance

Information about hand hygiene was widelydisseminated. In all nursing units surveyed, the

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10 Sahrul Bariyah et al.

awareness of hand hygiene had been discussed at staffmeetings and infection control meetings (as confirmedby meeting minutes), included in staff educationalprograms (as confirmed by continuing educationrecords), and 82% of 155 staff members who wereanonymously surveyed confirmed that they werefamiliar with the HHPG.

Appropriate supplies and products were readilyavailable on all patient care units observed, and staffwere aware of the written policy prohibiting artificialnails.

Nevertheless, the majority of nursing units did notmonitor hand hygiene compliance routinely. Thefindings revealed that hand hygiene compliance ratesranged from 24% to 89% (mean, 56.6%) per unit.

After analyzing the Hand Hygiene surveillance auditfinding, a training program was scheduled for allcategories of staff (nursing, allied health, and supportservices staff). We aimed for 80% of KPJ DSH to betrained. At the same time, we conducted monitoring onHand Hygiene facilities and hand hygiene practices to allhealthcare workers including consultants according tothe surveillance schedule.

With the findings above our team has developed apolicy on hand hygiene and strategies to sustain andensure full compliance by each healthcare personnel:

1. The policy states that all healthcare providers mustcomply to the hand hygiene policy.

2. The hospital must be well-equipped with handhygiene facilities as follows: Installation of HandHygiene facilities (hand washing areas and handrub facilities) at all clinical and non clinicalservice areas. The team surveyed the availabilityand locations of hand washing facilities and areas

with alcohol-based hand rub dispensers andarranged for installation of additional dispensersin locations that lacked them. The alcohol-basedhand rub dispensers will be placed at all the pointsof engagement (patient contact areas) (Fig. 1).‘Points of engagement’ refers to areas that areeasily accessible to staff by being as close aspossible to where patient contact is taking place tomake hand hygiene more convenient.

3. To reinforce good hygiene practices our localcommittee conducted awareness campaign andtraining based on a structured training plancovering indication and purpose of hand hygieneand a demonstration on proper hand hygienetechnique. Hand hygiene posters are displayed atall clinical and non-clinical service areas. They areplaced near to hand washing basins, corridors andmade easily visible to staff, patients and visitors.

With baseline data gathered, the team launcheda comprehensive education and promotionalcampaign that included group presentations aswell as written information for hospital staff andpatients about the importance and the propertechniques of hand washing. As a key element ofthe program, the team also encouraged themanagers of all units to serve as hand washingchampions, observing staff and reinforcing themessage about the importance of hand hygiene.

4. It is our aim to train everyone working in thehealthcare system on infection control practices,of which hand hygiene is one of the mostimportant practices. The HHPG has beenincorporated and is a mandatory agenda in theorientation program for new employees.

Fig. 1. Points of Engagement of Hand Hygiene (In Patient)

Receive patient

PROCEDURE

✭

Orientate Patient / relative ✭

Patient assessment ✭

Consultant review ✭

Nursing Management ✭

Procedure ✭

Discharge

UM, SRN, C/A & CLERK

RESPONSIBILITY

UM, SRN, C/A & CLERK

UM & SRN

CONSULTANT, UM & SRN

UM, SRN

CONSULTANT, UM, SRN, C/A & CLERK

Key: ✭Your moments for Hand Hygiene✭

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Sharing Experience: Improving Hand Hygiene 11

5. To ensure compliance, audits will be conductedtwice in a year by certified assessors andsurveillance audits will be conducted threemonthly to evaluate the compliance of the handhygiene practices. In order to confirm that allaspect of hand hygiene protocol is being followed,the team has revised the hand hygiene surveillanceform, tailoring it to the specific areas and issuesbeing audited. The checklist is user-friendly - asimple yes/no checkbox for each audit criteria(Appendix A).

DISCUSSION

The Hand Hygiene Guideline was widelydisseminated to all nursing units, the majority of staffmembers were familiar with it, and hand hygienefacilities were readily available. Multiple barriers toadherence to clinical practice guidelines orimplementation of research findings have been described.In our study, lack of awareness and external barriers wereunlikely to be important because most staff membersknew about the HHPG and its recommendations andadequate copies were made available.

Improving and maintaining effective hand hygienehabits requires a combination of assessment, education,and ongoing monitoring. Encouraging good handhygiene practices among healthcare workers is a goodstart but more should be done to educate the public aboutkeeping their hands clean when they are in a healthcarecentre. Focusing on improving hand hygiene was part ofa larger hospital-wide infection control effort. But inorder to get there, everyone who works with or aroundpatients must take personal responsibility for good handhygiene.

CONCLUSION

It is clear that effective implementation of guidelinesrequires a comprehensive approach involving variouslevels within the organization. Infection controldepartments are unlikely to be able to implementsuccessfully such multidisciplinary efforts without thesupport of the management.

REFERENCES

1. WHO. The Global Patient Safety Challenge 2005 -2006 "CleanCare is Safer Care. Geneva, WHO, 2005.(http://www.who.int/patientsafety/events/05/GPSC_Launch_ENGLISH_FINAL.pdf)

2. Pittet D, Boyce JM. (2003) Revolutionizing hand hygiene inhealth-care settings: guidelines revisited. Lancet InfectiousDiseases; 3: 269-70.

3. Guideline for Isolation Precautions in Hospitals. Centers forDisease Control and Prevention 1996.(http://www.cdc.gov/ ncidod/dhqp/gl_isolation_ptII.html)

4. Lazzari S et al. (2004) Making Hospitals Safer: the need for aglobal strategy for infection control in healthcare settings. WorldHosp Health Serv; 34:36-42.

5. World Health Organization. WHO Guidelines for Hand Hygienein Health Care (Advanced Draft). Geneva: World HealthOrganization, 2006.(http://www.who.int/patientsafety/information_centre/ghhad_download/en/index.html)

6. Pittet, D. et al (2006) Evidence-based model for handtransmission during patient care and the role of improvedpractices. The Lancet Infectious Diseases; 6: 10, 641-652.

7. Won SP et al.(2004) Handwashing program for the prevention ofnosocomial infections in a neonatal intensive care unit. InfControl Hosp Epidemiol 2004; 25:742-46.

8. Eckmanns, T. et al (2006) Hand rub consumption and handhygiene compliance are not indicators of pathogen transmission inintensive care units. Journal of Hospital Infection; 63: 4, 406-411.

9. Haley RW et al. (1985) The efficacy of infection surveillance andcontrol programs in preventing nosocomial infections in UShospitals. Am J Epidemiol; 121:182-205

10. Pittet D et al. (1999) Compliance with handwashing in a teachinghospital. Ann Int Med 1999; 130:126-30.

11. Jenner, E. et al (2006) Discrepancy between self-reported andobserved hand hygiene behaviour in healthcare professionals.Journal of Hospital Infection; 63: 4, 418-422

12. Pittet D et al. (2000) Effectiveness of a hospital-wide programmeto improve compliance with hand hygiene. Infection ControlProgramme. Lancet; 356:1307-12

13. Creedon, S. (2005) Healthcare workers' hand decontaminationpractices: compliance with recommended guidelines. Journal ofAdvanced Nursing; 51: 3, 208-216

14. Johnson PD et al. Efficacy of an alcohol/chlorhexidine handhygiene program in a hospital with high rates of nosocomialmethicillin-resistant Staphylococcus aureus (MRSA) infection.Med J Aust 2005; 183:9-14

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12 Sahrul Bariyah et al.

HAND WASHING YES NO N/A COMMENT F/UP

1 Dip all fingers of right hand into left palm filledwith hand rub solution, pour hand rub solutionover to right palm and dip all fingers of left handinto hand rub solution.

2 Rub hands palm to palm.

3 Palm to palm with fingers interlaced.

4 Right palm over left dorsum with interlacedfingers and vice versa.

5 Palm to palm with fingers interlaced.

6 Backs of fingers to opposing palms withfingers interlocked.

7 Rotational rubbing of left thumb clasped inright palm and vice versa.

II: SURVEILLANCE AUDIT ON PROPER TECHNIQUE OF HAND RUB METHOD

HAND WASHING YES NO N/A COMMENT F/UP

1 Wet hands with water.

2 Apply enough soap to cover all surfaces.

3 Rub hands palm to palm.

4 Right palm over left dorsum with interlacedfingers and vice versa.

5 Palm to palm with fingers interlaced.

6 Backs of fingers to opposing palms withfingers interlocked.

7 Rotational rubbing of left thumb clasped inright palm and vice versa.

8 Rotational rubbing, backwards and forwardswith clasped fingers of right hand in left palmand vice versa.

9 Rotational rubbing of right wrist clasped inleft palm and vise versa.

APPENDIX A

I: SURVEILLANCE AUDIT ON PROPER TECHNIQUE OF HAND WASHING METHOD

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Sharing Experience: Improving Hand Hygiene 13

III: HAND HYGIENE ASSESSMENT FORM

FACILITIES YES NO COMMENT F/UP

Hand hygiene facilities– Wash basin with anti splash devices– Elbow type

Hand hygiene supplies• Liquid soap solution• Liquid soap dispenser• Paper Hand towel

Hand rub is visible and easily assessable

Posters on hand hygiene clearly displayed– Washroom, sink, and notice board

A foot operated waste bin

STAFF

Attendance on Hand Hygiene training

Are any members of staff observed to be wearing hand jewellery?

Do any members of staff observed havelong nails, nail vanish?

When asked were staff able to :Locate Hand Hygiene policy

Demonstrate an acceptable Hand Hygienetechnique

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14 KPJ Medical Journal 4:14–19 (2010)

INTRODUCTION

Way back more than 145 years ago, FlorenceNightingale noted in her preface that the very firstrequirement in a hospital is that it should do the sick noharm.1 In 2005 it was noted the morbidity and mortalityamong hospitalized patients throughout the UnitedStates has heightened concerns about professionalcompetency.2 Error can occur in any system involvinghuman beings and today as we look at patient safety in amultidimensional approach, this leaves the healthcareproviders under increased scrutiny to provide effectivecare that is safe.

KPJ being the nation’s largest healthcareconglomerate strives to cultivate safety and quality in itsdaily work culture. During the KPJ Medical Workshopin 2008, KPJ Seremban Specialist Hospital and KPJSelangor Specialist Hospital were given the responsibilityto work on the International Patient Safety Goal:Reducing the Risk of Patient Harm Resulting from Falls3,4

that was adopted from the list of International PatientSafety Goal proposed by Joint Commission Internationalin 2008. KPJ Seremban Specialist Hospital accumulatedthe higher- than-average number of patient falls in year2008 within the KPJ group of hospitals and it was indeeda challenge to take up this patient safety goal.

Patient falls are a challenging safety and qualityrelated issue in acute care settings where an agingpopulation and persons with physical and cognitivelimitations are exposed to an unfamiliar and potentiallyhazardous environment.5 In this transformational century,in a world of high-tech treatment and fast-movingmedical advancements, it is ironic that something assimple as a patient falling is such a problem. There is aneed to emphasize the importance of patient falls asthese are frequently cited complaints and have been thesubject of over 600 negligence claims via the NHSLitigation Authority in the past 10 years.6 This is

associated with patients’ family often perceiving falls asa failure in the duty of care by of the hospital staff butthis can be unfair, as many falls cannot be prevented andare a feature of the underlying medical problem or frailtyof the patient himself.

OBJECTIVE

This article describes hospital wide strategies forprevention of falls and the prevention precautions weredeveloped based on the contributing factors from rootcause analysis of retrospective data collected on theincidents of falls and near misses in the hospital.Although the fall prevention programme is still in itsinfancy, the initial results are encouraging.

METHODS

Definitions

Fall is defined as the loss of upright position thatresults in landing on the floor, ground or an object suchas furniture or a sudden, uncontrolled, unintentional, nonpurposeful, downward displacement of the body to the

ABSTRACTThis article collates the strong evidence based approaches in developing solutions to reduce therisk of harm resulting from patient falls throughout the hospital. A structured assessment tool toidentify patients who are at high fall risk and appropriate fall prevention interventions has beendeveloped. KPJ Medical Journal 2010; 4:14–19

Key words : Patient falls, risk, assessment tools.

Maygala A.,1 Primuhasa Putra SHA,1 Aziz AR,1 Suzana K,1 Ainol MR,1 Zainab MN,1

Jaliah MJ,2 Halimaton DY,2 and Sumaria AM2

Reducing Risk of Patient Harm Resulting From Falls

1KPJ Seremban Specialist Hospital

2KPJ Selangor Specialist Hospital

Correspondence:Maygala Arumugam, SRN, SCM, Dip Ed,BSc, MSN,Operations Manager KPJ Seremban Specialist Hospital,Jalan Toman 1, Kemayan Square,70200 Seremban, Negeri Sembilan.Email: may@ssh.kpjhealth.com.my

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Reducing Risk of Patient Harm Resulting From Falls 15

floor or hitting another object like a chair or a stair.Patients who are assisted to the floor by staff and wouldhave fallen without the staff assistance will also beidentified as fall.8 Falls are not due to any intentionalmovement or extrinsic force and hospital patients are atgreater risk of falling compared to other people in thecommunity.7

A near fall (near miss) is a sudden loss of balance thatdoes not result in a fall or other injury. This includes aperson who slips, stumbles or trips but is able to regaincontrol prior to falling. An un-witnessed fall occurswhen a patient is found on the floor and neither thepatient nor anyone else knows how he or she got there.9

Some classify falls based on environment, as well asphysiological factors and another approach suggests that falls be classified as accidental, unanticipatedphysiological or anticipated physiological.10

Accidental falls occur when patients fallunintentionally, for example trip or slip because ofenvironmental factors such as slippery or wet floor.

Unanticipated physiologic falls occur due to physicalconditions that cannot be predicted until the patient fallssuch as a fainting spell or a seizure.

Anticipated physiological falls occur in patients

when they have been assessed and rated as risk of fallingdue to some characteristics identified in the individualsuch as impaired gait or on sedation.

Analysis

A retrospective analysis of all patient falls that wereregistered amongst the inpatients and outpatients in theSeremban hospital was taken into this study.

A data collection spreadsheet was used to analyze andbetter understand patient falls in this 130 bedded hospitalfrom January to September 2008. Information wascollected on related factors of the falls as they occur, tofurther track and communication patterns, issues, andpotential interventions required.

RESULTS

An analysis of what the patients were attempting to doat the time of a fall and the demographical data of thefalls is shown in Table 1.

The root cause factors contributing to falls wereidentified and the findings are tabulated as in Fig. 1.

Level Related to the Person’s Condition Related to the Environment (Extrinsic)(Intrinsic)

Fig. 1. Contributing factors to falls

● Environment (wet floor, floor glaze, cluttered room, poorlighting, inadequate handrail support, loose cords or wires)

● Inappropriate footwear● Wheels on beds ● Prolonged length of stay● Placing child on adult bed ● Beds left in high positions

● Individual reactions to medications● Without companion

An

tici

pat

edU

nan

tici

pat

ed

● Recent history of falls (mostsignificant risk factor)

● Incontinence, etc.● Mobility/balance/strength problems● Dizziness/vertigo● Age (6 months to 60 years)● Overall poor health status

● Seizures● Cardiac arrhythmias● CVA or TIA● Syncope

Table 1 — Time and location factors related to falls

Description Patient Type Time Site/Activity Companion Available

Adult Paeds AM PM ON Bed Sleeping Toilet Mobilizing Yes No21 3 9 6 10 9 3 7 6 7 18

Total Falls 25

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16 Maygala et al.

The contributing risk factors in the ‘unanticipated’group is considered as ‘general risk factors contributingto falls’ as they can happen to any patient, while the‘anticipated’ group was categorized as ‘specific riskfactors’ as it identifies those patients who are at risk offalling. The interventions were formulated based onthese general and specific contributory risk factors tofalls. The interventions for the general risk to fall wereidentified as ‘standard’ or ‘universal fall preventionprecautions’ for all patients. The interventions forspecific risk factors were identified as ‘strictprecautions’ targeted specifically for those who are athigh risk of falling (Fig. 2).

It was noted in National Patient Safety Goals (NPSG)of 2008, 4 the specific requirement firstly is to "assessand periodically reassess each patient's risk for falling,including the potential risk associated with the patient's

medication regimen, and secondly to take action toaddress any identified risks."

Assessment and reassessment for risk of falling areperformed for the following patients;

• On admission and transfer in.• All confused patients, regardless of age.• All elderly patients (more than 65 years old)• All post operative cases.• All post delivery patients. • All post invasive procedures such as scopes and

angiogram.• When there are changes in the medical condition of

the patient (e.g. changes in glucose level/changesin vital signs).

• Following a fall (on regular intervals) as a post fallmanagement intervention.

Standard Precautions

Unanticipated Nursing Staff risk factors To nurse on a low bed with side rails and monitor patient’s coordination and balance.

Education Orientate patient and family to room environment, toilet facilities, brief on side effects ofmedication where applicable and advise on suitable footwear.

Equipment Lock all moveable equipments and place personal care items within reach.

EnvironmentProvide physically safe environment with adequate lighting.

Strict Precautions

Anticipated Nursing Staff risk factors Place patient in room identified for close observation and place indicators such orange ID band

as an indicator of risk to fall.

Medical Staff Clinician to review medication and treat the underlying medical conditions.

Fig. 2. Inpatient strategies to reduce the risk of patient harm resulting from falls

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Reducing Risk of Patient Harm Resulting From Falls 17

DISCUSSION

Assessment tools

There are several risk assessment tools available suchas the Morse Fall Scale (MFS)10 and Hendrich Fall RiskAssessment Tool (Fig. 3).10,11 MSF was being usedthroughout the KPJ Group. However, falls were stilloccurring and based on the contributing factors ofretrospective patient fall data, the assessment criteriawere reviewed and are now known as KPJ Fall RiskAssessment Tool (KPJ FRAT).

The main advantages of KPJ FRAT are:1. Focuses on required interventions for the general risk

and specific risk factors as it encompasses most of thecriteria of the other 2 tools.

2. Rating mechanism is easier and user friendly ascompared to the MFS and Hendrich. Both MFS andHendrich Scale require the checklist to be completed,however a "yes" to any one of the KPJ FRAT criteria

considers the patient to be at high risk requiring thestandard and strict precautions to be undertaken.

3. There are only two risk categories of patientsrequiring two types of interventions:• standard fall precautions. • strict fall precautions.

The main disadvantage of this assessment is thatnearly every patient will be put into the categoryrequiring standard fall precautions.

Outpatient fall risk assessment and fallprevention strategies

Besides focusing on reducing falls amongst thehospitalized patients, awareness and skills to provide asafer patient environment for outpatients wasundertaken. Outpatient strategies to reduce the risk ofpatient harm resulting from falls were developed basedon the selected ‘fall risk’criteria as tabulated in Fig. 4.

Fig. 3. Comparison of the risk factors of the fall assessment tools

Risk Factors Hendrich11 (MFS)10 KPJ FRAT

Recent History of falls × × ×

Secondary diagnosis × ×

Ambulatory aid × ×

IV /Heparin lock × ×

Poor mobility/generalised weakness × × ×

Mental status × ×

Confusion /disorientation × ×

Depression × ×

Dizziness / vertigo × ×

Altered elimination × ×

Multiple medication ×

Environment ×

Risk assessment score Rated as High, Rated as High, Requires ‘Standard’Moderate or Low Moderate or Low or both ‘Standard &

Strict’ Precaution

Risk Criteria Precautions

Fig. 4. Outpatient precautions to prevent falls based on the ‘fall risk’ criteria

i. Attend to patient immediately. ii. Accompany / allow family members to be with the

patient at all times throughout the treatment.iii. A&E / OPD: Place orange label as indicator of risk

to fall.iv. Strap patient to stretcher/ wheelchair when doing

procedures.

● Mobility: those using the wheelchair, stretcher orwalking aides.

● Patients with unsteady gait.● Children below 12 years of age and● Elderly who is more than 65yrs.

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18 Maygala et al.

Team approach

The responsibilities lie on those working within thespecified areas to ensure compliance of the followingoutpatient standard fall precautions;

i. Hallways and patients areas are well lit.ii. Hallways and patient areas are uncluttered and

free from spills.iii. Tables and chairs are sturdy.iv. Display of fall prevention policy to the public.v. Availability of brochures on fall prevention

vi. All assistive devices such as wheelchairs, walkersand panel frames along the walls are in goodcondition and functioning well.

vii. Unsafe situations are dealt with immediatelyeither by dealing with the situation directly ornotifying the appropriate staff and ensuringcorrective actions are taken immediately.

The strategies to reduce the risk of patient harmresulting from falls are elaborated in Fig. 5.

This assessment and prevention strategies can helphealthcare providers learn to identify the patients havinghigh risk for sustaining a serious injury from a fall andimplement interventions to prevent or mitigate theseinjuries before this happens.

Post implementation data

After implementing the fall prevention strategies thedata on falls and near misses were continuouslymonitored, however only one data point was analyzedthat is the rate of falls. The rate of fall is a measurementof risk that tells you how many falls are expected forevery 1000 bed days of care (BDOC). Bed days of caretells you how many days patients were in the beds,locally known as inpatient days.3

For every 1000 bed days of care you can expect tohave about 4 falls. Prior to intervention it was found that for every 1000 bed days of care there were about6.42 falls from January 2008 till September 2008. Thefall prevention precautions structured and implemented

Fig. 5. Flowchart showing fall risk assessment & risk reduction to falls

Patient Admitted / Transfer In

Inpatient Outpatient

Assessing KPJFall Risk

Assessment Tool

‘YES’ to any one ofKPJ FRATquestions

‘NO’ to all of KPJFRAT questions

‘YES’ to any oneof KPJ FRAT

questions

ImplementInpatient

Standard FallPrecautions

Discharge / Transfer Out to other Hospital

ImplementInpatient

Standard & StrictFall Precautions

Evaluate riskto fall at every

shift and PRN

* Re-assessfor changes in

Risk level to fall

‘NO’ to all of KPJFRAT questions

High Risk to Fall Criteria• Mobility – wheelchair / stretcher• Unsteady Gait• Using Walking Aides• Children below 12 years• Elderly who is more than 65 years

Outpatient Strict Fall Precaution• Attend to Patient immediately• Accompany / Allow family members to be with the

patient at all times.• Remind patient / family to call for assistance

when needed.• A&E: Place orange label with falling star with

patient’s name & MRN on the requisition formswhen sending for other investigation / treatmentto other services.

• Strap patient to stretcher / wheelchair when doingprocedures.

• Chaperon / accompany patient upon completionof procedure/treatment until they leave thehospital premises.

* - Changes in condition

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Reducing Risk of Patient Harm Resulting From Falls 19

ACKNOWLEDGEMENTS

1. Dr Wan Hazmy Che Hon, Medical Director of KPJ SerembanSpecialist Hospital.

2. Y.Bhg. Dato’ Dr Shahrudin Bin Mohd Dun Medical Director, KPJSelangor Specialist Hospital.

3. En Mohd Johar Ismail, General Manager of KPJ SelangorSpecialist Hospital.

4. Risk Committee Members of KPJ Seremban Specialist Hospital& KPJ Selangor Specialist Hospital.

REFERENCES

1. Donaldson MS, An Overview of To Err is Human: Re-emphasizingthe Message of Patient Safety, 2005.

2. Friesen MA, Farquhar MB, Hughes RG, Center for AmericanNurses: The Nurse’s Role in Promoting a Culture of PatientSafety, 2005.

3. VHA National Center for Patient Safety, National Center forPatient Safety 2004 Falls Toolkit, May 2004.http://www.visn8. med.va.gov/patientsafetycenter/

4. National Center for Patient Safety, 2008, Fall prevention toolkit,United States Department of Veterans Affair.http://www.va.gov/ NCPS/SafetyTopics/fallstollkit/index.html

5. Tzeng HM, Yin CY. The staff –working height and the designingregulation height for patient beds as possible causes of patientfalls. Nursing Economic 2008.

6. Mid Yorkshire Hospitals NHS Trust Mid Yorkshire Hospitals NHSTrust Reducing Patient Falls Project January 2001 – March 2002

7. Hairon N. Using a range of interventions to prevent falls in thehospital. Nursing Times 2007;103:23-24.

8. Australian Council for Safety and Quality Healthcare, Preventingfalls and harm from falls in older people, 2005.

9. Rubeinstein LZ, MacLean C. Quality Indicator for theManagement and Prevention of falls and Mobility Problems inVulnerable Adults. Annals of Internal Medicine 2001;135: 686-693.

10. Morse JM. Enhancing the safety of hospitalization by reducingpatient falls. American Journal of Infection Control 2002;30:376 -380.

11. Heindrich A. Inpatient falls: Lessons from the Field. PatientSafety & Quality Healthcare, 2006.http://www.psqh.com/aug 09/falls.html

from October 2008 till December 2008 helped thehealthcare providers learn to identify the patients whohave the highest risk for sustaining a serious injury froma fall and implement the interventions to prevent ormitigate these injuries. The post implementation datareflects for every 1000 inpatient days the fall ratedecreased to 2.18 falls over a period from January 2009till September 2009 (Table 2).

What to do in the event of a patient fall

Although precautions are taken appropriately and if a fall occurs, the incident needs to be attended toimmediately and following the post-fall assessment anincident report should be completed. Fall preventioninterventions should be reviewed and care plans shouldbe modified appropriately.

CONCLUSION

Falls and the associated negative outcomes in patientsare of significant concern. The etiology of hospitalpatient falls is multi-factorial including both intrinsicand extrinsic factors. Many of the health problems thatincrease the chance of falling are known and aretreatable. Although leaders in healthcare may focus on fall rates but it is important not to lose sight of ourgoal which is to reduce harm resulting from falls andreduce the severity of fall related injury.

Preventive strategies starts with assessing andreassessing periodically the patient’s modifiable fall riskfactors in a collaborative team approach towards ensuringthe safety of an individual in a healthcare setting. Thechallenge for healthcare professionals will be to supportpatient safety and quality of care initiatives by earlyidentification of patients at risk for falling, and implementthe interventions to prevent falls and related injuries.

Table 2 — Falls per 1000 BDOC

Statistic Related to Falls(Jan - Sept. 2008 Vs Jan - Sept. 2009)

0

5

10

15

20

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1 1 0 1 1 0 3 0 0 7

0.3 1.1 1.6 0.7 0.6 1.1 0.4 0.7 0 6.42

0.3 0.3 0 0.3 0.3 0 0.9 0 0 2.18

JAN FEB MAR APR MAY JUNE JUL AUG SEPT TOTAL

1 3 5 2 2 3 1 2 0 19Total Fall 2008

Total Fall 2009

Fall Per 1000 Inpatient Days 2008

Fall Per 1000 Inpatient Days 2009

Fall / 1000Inpatient Days

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20 KPJ Medical Journal 4:20–22 (2010)

Zaharah Osman, SRN, MSc

A System Approach to the Reduction of MedicationAdministration Error Among Nurses

Correspondence: Zaharah Osman,KPJ Healthcare Berhad, 7, Persiaran Titiwangsa 3,53200 Kuala Lumpur.

ABSTRACTNurses are responsible for correct administration of medication. Drug administration is an integralpart of the nurse’s role. Nurses committing medication administration error is inevitableconsidering that nurses are the ultimate person to administer the drug to patients, although theerror could have been contributed by others. This paper discusses the issues of medicationadministration error and focuses attention on the nurse as the sole weak point in the chain and onthe general perception that nurses are solely accountable although the prescribing process ismultidisciplinary in nature. KPJ Medical Journal 2010; 4:20–22

Key words : Medication error, nurses.

BACKGROUND

"A medication error is generally defined as adeviation from the physician’s medication order as perwritten on the patient’s chart".1 Drug administration is anintegral part of the nurse’s role. Nurses are responsiblefor correct administration of medication, yet medicationerrors are a persistent problem associated with thenursing practice.2 The likelihood of a nurse causing erroris inevitable because she is in the front line in carryingout the medication order prescribed by doctors.

There are several factors in the ward setting impactingon the nurse’s ability to administer medicationcorrectly.3 A study conducted in US hospitals found thatfactors related to workplace distraction accounted for43%, staffing issues such as shift changes and floatingstaff accounted for 36% and workload increasesaccounted for 22% of incidents.4,5

Medication error is a worldwide problem. Medicationerrors occurred in 5.07% of the patients admitted eachyear to US hospitals.5 Administration errors accountedfor 51% of written incident reports. Further, 24% of thereports described transcription/verification errors, 16%described ordering/prescribing errors, 10% describeddispensing/delivery errors and 29% describedadministration of wrong dose.5

SYSTEM FACTORS

Nurses manage a wide range of challenges in ademanding and often hectic workplace; attending topatients, doctors, visitors, telephone calls, billinginquiries, charges, nursing care and assisting in doctor’sprocedures, preparation of patient for surgery, sendingpatients to the operation theatres for radiological

procedures and physiotherapy. They also collect,dispense and administer medications, trace laboratoryresults, manage and collect ward stock, attend andfacilitate housekeeping and maintenance. Thecombination of these factors may lead to bad outcomeslike medication error.

Shortage of staff and high turnover of RNs withincreasing numbers of beds, expansion of wards withouttaking into consideration of staff availability, forcenursing managers to resort to the use of extended workshifts and overtime. "The risk of making an error wassignificantly increased when work shifts were longerthan twelve hours, when nurses worked overtime, orwhen they worked more than forty hours per week".7

Within the nursing fraternity preliminary anecdotalreports suggest there are several factors in theenvironment impacting on the nurse’s ability toadminister medication correctly thus putting nurses atrisk of making errors; high bed occupancy, patient acuitylevels, shortage of nurses, lack of support from othersupport services, difficult patients who refuse to takemedication served to them in time, multi-tasking, multi-disciplinary ward, multi-specialty medical consultants,uncooperative doctors, illegible or poor hand writtenorders, verbal orders, unclear regime, lack ofinformation, using dangerous abbreviations, prescriptionerror, unsystematic dispensing, inefficient and poordelivery system by pharmacy, insufficient supply ofdrugs and confusion with complex drugs eg; look alike,sound alike drugs, new drugs, unfamiliar drugs, multipledrugs dosage and improper storage of drugs.

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Reduction of Medication Administration Error Among Nurses 21

IMPACT ON NURSES

The nursing profession has always regarded patientsafety as being of the utmost importance. FlorenceNightingale stated that "the very first requirement in ahospital that it should do the sick no harm".8 Nurses aregenerally willing to accept responsibility for their errorsand did what they could to reduce any harm to thepatient.9 Most nurses feel upset and emotionallyaffected. They feel paralyzed and powerless and theirself-confidence is shattered. Their loss of control and thefeeling of guilt grow to the extent that even years afterthey still struggle to handle the stress caused by theerror.9,10 The psychological trauma can beoverwhelming to a nurse to a certain extent that it affectsthem personally and professionally.10 The way theincident is handled by their superior may make the nursefeel depressed, neglected and betrayed. Nurses feelintimidated with disciplinary actions taken against themincluding termination and loss of benefits.

The preconceived idea that the nurse is at fault hasbeen perpetuated in the hospital incident submissionreport and findings where over the years the nurses isblamed for the incident. Generally investigation findingsblame the nurse for failing to comply with drugadministration policies and procedures and it is alwaysperceived by the nursing manager as an "attitude"problem.

Hospital administrators fail to take into accountfactors in the environment impacting on the nurse’sability to administer correctly. The temptation to blamethe nurse is common and this is very evident in the rootcause analysis findings. As the consequences of the onesided and bias report, nurses are afraid to report errorsfor fear of disciplinary action that will impact on theirimage and professional development. A punitive, person-centered approach will not improve the patient safety.Nurses should be allowed to learn from their mistakesthus preventing them from making other similarmistakes in the future.

Mistakes are a sign that a safety problem exists withinthe hospital setting and not that a nurse is negligent.When conducting an investigation, very little focus wasgiven towards prescribers, pharmacists, dispensers andclerks that can contribute to the occurrence ofmedication errors. A study revealed that a dispensingerror accounted for 0.87% to 2.9%1 of total number ofmedication related errors. In another study it was foundthat a total of 2103 errors were detected during the 1-year study period among doctors and pharmacists withan overall rate of errors being 3.99 errors per 1000medication orders.8

The newly graduated nurses lack the ability toundertake drug calculations and this deficiency has beenattributed to poor basic mathematical skills and lack ofexperience in the use of formulas.12,13,14 This lack ofbasic mathematical skills is further compounded withlack of understanding of drug indications, contra-indications and methods of dilution, route and side

effects. Overall, 40% of the nurses who experiencemedication error have less than one year of workexperience.6 It is perceived that many of the nurses arejunior and naive; lack of confidence, language barrier,fear of been ridiculed and feeling inferior are commonbarriers to seeking clarification. It is perceived that thedoctors, senior nurses and ward managers who do notlike to be disturbed and unapproachable, unfriendly andarrogant are common barriers to effectivecommunication. Nursing managers claim that theyalways emphasise that nurses should seek clarificationwhen unsure of prescription or illegibly written orders.

STRATEGIES TO IMPROVE MEDICATIONADMINISTRATION SAFETY

"The probability of an accident can never beabsolutely zero; however their occurrence can beminimized through a systems approach to the reductionof medication error".3 We cannot deny that medicationerrors have serious implications. Strategies should bedeveloped to address the factors underlying an incidentthat are usually the consequence of breakdowns in thehospital system. A substantial improvement in drugadministration safety in the nursing units will not occuruntil a system approach is adopted.

All professionals ie. doctors, pharmacists, nurseeducators and nursing managers should develop aprogram to ensure that nurses are trained and haveadequate theoretical knowledge of pharmacology, basicmathematical skills and accurate application offormulas. Lack of communication between nurses anddoctors is the link to medication error.15 We need tocreate an environment of learning that allows juniornurses to seek and ask question whenever in doubt. Weshould provide them with adequate resources druginformation, sufficient devices e.g. infusion pumps andclose supervision through a preceptorship program.

Nursing managers should avoid the use of doubleshift, 12-hours shift system and overtime shift since longworking hours have significant impacts on frequency oferrors. They should not allow a nurse to work more thanforty two hours per week but allow rest day as perschedule rather than calling them for locum shift whenfaced with staff shortage.

Multiple roles played by nurses in managing andaccommodating all types of patients from adult topediatric to newborn, patients with multiple conditions,managing multi-disciplinary wards and multi-disciplinarydoctors should be seriously reviewed by the hospitaladministrators. Allowing nurses to focus more on onediscipline will improve their expertise in the field. A goodnurse-doctor-pharmacist relationships will be developed.Pharmacists can play their role by having regular sessionswith nurses to educate them in the use of commonly useddrugs particularly newly introduced drugs and "high alertdrugs". Doctors should highlight to the nurses drugsindications, side effects and document drug regimes in

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22 Zaharah Osman

detail and specify the method of dilution and routeclearly.

CONCLUSION

Drug administration error is a problem in all healthcaresettings. A system approach to its improvement isimperative as compared person-centred approach. Asystem approach will improve safety substantially.Unfortunately nurses continue to take the blame andneedlessly accept critique; as a result the systemapproach has never been addressed. It is imperative thatnursing managers should seriously examine the issue ofmedication administration error and take proactiveaction in dealing with medication error from the nursingperspective and at the same time a well-reasonedapproach by management is important to itsimprovement.

REFERENCES

1. Allan, EL, Barker, KN. (1990). Fundamentals of medication errorresearch. American Journal of Hospital Pharmacy, Volume 47,Issue 3 555-571.

2. O’Shea, E. (1999). Factors Contributing to medication errors: aliterature review, Journal of clinical Nursing. 8(5): 496-504

3. Anderson, D., Webster, C., (2000). A systems approach to thereduction of medication error on the hospital ward, Nursing andHealth care Management Issues.

4. Bond, C.A., Raehl, C.L., Franke T., (2001). Medication Errors inUnited States Hospitals. Pharmacotherapy.

5. The United States Pharmacopeia (USP) 2003 Annual Report.Medical News Today 19 November 2003.

6. Antonow, J., Smith A., Silver, M., (2000). Medication ErrorReporting: A Survey of Nursing Staff, Journal Nursing CareQuality 2000:15 (1): 42-48 (2000).

7. Medication Administration Error – Nursing Analysis Report 2009 8. Rogers, A. Wei-Ting Hwang, Scott, L., Aiken, L., Dinges, D.

(2004). The Working Hours Of Hospital Staff Nurses And patientSafety. Health Affairs, 23, no. 4 202-212 doi: 10. 1377/hlthaff.23.4.202.

9. Nightingale F. Notes on Hospitals, Enlarged and for the Most PartRe-written. 3rd ed. London, England: Longman Green LongmanRoberts & Green; 1863.

10. Mc Bride, K., Foureur, M., (2006). Medication AdministrationErrors: Understanding the issues, Australian Journal of AdvancedNursing Volume 23.

11. Schelbred A., Nord, R. (2007) Nurses’ experiences of drugadministration errors. Journal of Advanced Nursing, 317-324.

12. Mayo, A., Duncan, D., (2004). Nurses perceptions of MedicationErrors: What we need to know for patient safety Journal NursingCare Quality Vol. 19, pp. 209-217.

13. Lesar, T., Briceland, L., Stein, D. (1997). Factors Related toErrors in Medication Prescribing JAMA. 277 (4): 312-317.

14. Pentin, J., Smith, J., Drug calculation: are they safer with orwithout a calculator? Br J Nurs. 9; 15 (14): 778-81.

15. Rice, J., Bell, M. (2005). Using dimensional analysis to improvedrug dosage calculation ability Journal of Nursing Education,2005 Jul; 44:315-318.

16. Page, K., McKinney, AA., (2007). Addressing medication errors-The role of undergraduate nurse education. Nursing EducationToday 219-24. 2006.

17. Croskerry, P., Shapiro, M., Campbell S., LeBlance C., Sinclair,D., Wren, P., Marcoux, M., (2008). Profile in patient safety:Medication Errors in the Emergency Department. AcademicEmergency Medicine Volume 11 Issue 3, Pages 289-299.

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KPJ Medical Journal 4:23–26 (2010) 23

BRIEF HISTORY

Case 1

A 54 year old Chinese gentleman was involved in amotor vehicle accident in December 1998; sustained aC4/C5 fracture with 50% displacement associated withcord transaction. Had fusion and plating of C4/C5 doneand was discharged after 3 months in hospital. Since theyear 2000, patient has been able to breathe well withoutthe ventilator and to date still has recurring chestproblems and bed sores.

Case 2

A 37 year old Chinese lady who had a history ofrecurrent thyoma in 2002 as well as myasthenia gravis.She stayed 3 months in the hospital and was dischargedafter 2 months. She passed away in 2003 due tometastasis. Her family claims that the hospital gave her thebest part of her life with the home ventilation program.

Case 3

A 27 year old Chinese man who was involved in amotor vehicle accident on his birthday in 2006, suffereda C3/C4 sublaxation with cervical cord contusion. Hehad dissectomy and fusion done. Stayed in hospital for 4 months and 3 months after discharge, he was able tobreathe well without the aid of the aid of the ventilator.

Case 4

A 58 year old Chinese lady who was involved in aroad traffic accident in June 2008 sustaining a burst C5fracture. She has been nursed in an open ward in agovernment hospital and has been told that she will beventilator dependent for the rest her life. The hospitaldoctors told the family that there was nothing else thatthey could do for her. She has been identified as our 4thcase and we have begun training her care giver. She hasbeen stable with minimal ventilator settings and will begoing home in mid October when her room is ready and

her maid has arrived to assist the patient’s husband withthe provision of care.

This unique program is the brainchild of ourconsultant anaesthetist Dr Richard Lobo who hasprevious experience running this program at HospitalUniversity Sains Kubang Kerian, Kelantan. When theprogram first took off, there were informal guidelineswith no proper references developed with theanaesthetist and ICU staff based on knowledge andcurrent practices at that point of time.

As KPJ Johor Specialist Hospital is a premier tertiaryprivatized healthcare facility, ventilator dependentpatients who are fit for discharge and fit the criteria forHMV rehabilitation will definitely experience costeffective care if they were home nursed as opposed tobeing hospital nursed.6 On a long term basis, hospitalbased care will be a financial burden especially forindividuals with limited resources. Therefore offeringventilator assisted individuals a chance to live their livesin their own familiar home environment and surroundedby their family would be the ideal solution.

METHODS

Discharge planning team

The discharge planning team facilitates andcoordinates the whole HMV program. The team consistsof Doctors, Anesthetist, Dietician, Physiotherapist, ICUnurses, the equipment specialist who will supply therequired equipment and who will assist the care giverwith equipment functions and the direct caregiver of thepatient. Once the need for HMV has been established,the discharge planning team is activated. Commitmentfrom both the caregivers and patient must be obtained toensure the success of HMV (Fig. 1).

ABSTRACTThe objective of this project is to help impaired individuals function to their highest possible level,reduce morbidity and mortality, decrease hospitalization through cost effective treatment andexperience improved quality of life.1

An increasing number of individuals use mechanical ventilatory support for all or part of the day;invasive and non invasive.2,3,4,5 KPJ Medical Journal 2010; 4:23–26

Key words : Home mechanical ventilation.

Nur Yasmin Jennifer Abdullah, SRN, MSc, and Richard Lobo, MBBS, MD (Anaes)

The Pathway for Home Mechanical Ventilation (HMV)

Correspondence: Nur Yasmin Jennifer Abdullah,KPJ Johor Specialist Hospital,39-B, Jalan Abdul Samad,80100 Johor Bahru, Johor, Malaysia.

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24 Nur Yasmin et al.

Patient

The patient must fit the criteria for HMV. The type ofpatient must be one who has no unstable coexistingmedical complications, stabilized ventilator settings,metabolically stable, infection free, good renal functionand haemodymically stable.7 Also the simplest ventilatormode and lowest possible FIO2 must be achieved.8,9

Patient needs to be strongly motivated, optimistic,resourceful, determined, flexible and adaptable.10

Caregiver

The caregiver is the individual who will provide all thecare for the patient at home. The success of HMV dependson the caregiver who must collaborate with members ofthe discharge planning team. The full realistic picture ofthe burden imposed on the caregiver must be told;disrupted schedules, financial strain and the provision ofround the clock care for the patient.1 The caregiver shouldpractice providing 24 hour patient care while in thehospital when resources for doing so are available.11

When they are able to provide the care needed, it buildsup their confidence and comfort not only for themselvesbut for the patient as well.1 Respite care must bearranged for the caregiver as caring for a ventilatorassisted individual (VAI) is hard work and their ownquality of life will be changed significantly as the illnessor disease of the VAI progresses and their own levels ofstress will increase as more is demanded of them.12

Training

Teaching has to be individualized to suit the patientand the family and this is the key to the success of HMV.1

Return demonstrations, techniques and their rationalescan be reviewed. Training involves the teaching of basicnursing care and competencies that the caregiver has toacquire; handling of equipment & monitoring of patientshealth status, care of tracheostomy, suctioning &physiotherapy, routine care of Foleys Catheter, handwashing and infection control, feeding via nasogastrictube/oral feeding and care of patient on ventilator.13,14

The frequency of monitoring will be determined basedon the patient’s current medical condition and dischargecare plan.14

Equipment/home environment optimization

Procurement of equipment is budget driven.Equipment specialists will assist the caregiver andchoice of ventilators should be based on patient’s clinicalneeds.10 The caregiver must become experienced inchanging ventilator circuits, cleaning the mechanicalventilator & troubleshooting when ventilator alarmsoccur and they should be comfortable using the manualresuscitation bag in case of equipment failure.1 Theymust be familiar with the use of the suction machineincluding battery powered aspirator for use during powerfailure.8,10 Other necessary equipment will includegenerator, backup battery, primary power source withgenerator, ripple mattress, oxygen tanks, oxygenconcentrator, commode, wheelchair, electrical bed, pulseoxymeter, carbon dioxide fire extinguisher, self inflatingbag valve mask device with reservoir, resuscitation bagwith tracheostomy attachments and mask of appropriatesize,10 TV, DVD and radio player for entertainment,computer to maintain social contacts and electronic BPset for monitoring blood pressure.

DISCHARGE PLANNING TEAM – FACILITATE & COORDINATE

IDENTIFIES PATIENT WHO FITS THE CRITERIA FOR HMV

CARE GIVER – WHO WILL PROVIDE ALL THE CARE AT HOME

TRAINING – INVOLVES TEACHING OF BASIC NURSING CAREHANDLING OF EQUIPMENT &

MONITORING OF PATIENT’S HEALTH STATUS

EQUIPMENT/HOME ENVIRONMENT OPTIMIZATION

DISCHARGE OF PATIENT FROM HOSPITAL

FEEDBACK / STRATEGIES TO OVERCOME PROBLEMS

➝

➝

➝

➝

➝

➝

➝

➝

Fig. 1. The pathway for home mechanical ventilation (HMV)

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The Pathway for Home Mechanical Ventilation (HMV) 25

Patient’s home environment must be supportive withnecessary adaptations identified early.1 Room on groundfloor with minimal stairs to allow easy mobilization onwheelchair and facilitate emergency evacuation and notnear the kitchen, air conditioned room, physical structurethat is safe and secure, doors wide enough to allowpassage of stretcher, bed and wheelchair, windows ofadequate size to allow easy escape and optimum viewing,sink for hand washing facilities, storage facilities fordisposable supplies, electrical outlets with 3 phase wiringwhich must be adequate to support the HMV equipment.

Discharge of patient

Patient will be discharged when the caregiver iscompetent, able to provide the necessary care, able to useall equipment that has been procured and are well versedwith emergency situations that may arise e.g. fire, naturaldisaster, power failure, ventilator failure, generatorfailure, equipment failure, obstruction of airway,accidental de-cannulation and deterioration of medicalcondition.8,15 Patient will be given an instruction bookletwhich will contain vital information will assist both thepatient and caregiver when the patient is discharged e.g.a checklist on daily nursing care schedule, vital signchart, intake and output chart, tracheostomy suctioningand care, feeding regime and a check list for emergenciesthat may arise. A system for communicating with thecase manager should be established to provide emotionaland psychological support after discharge.1

Homevisits & follow up

Home visits will be conducted by the dischargeplanning team to assess the patient’s condition and skilladaptability of the caregiver16 after the first 48 hours postdischarge and thereafter through intermittent phone callsand visits. It is recommended that the case manager keepin contact with the patient and family a few months postdischarge to gather any valuable information that willbenefit future patients.1

RESULTS

There were 3 cases on HMV from the 90s to date inJohor Specialist Hospital and two of them have survivedand are living complication free lives without theventilator. There were two guidelines drawn up in 2007with proper referencing; one for the nurses of theIntensive Care Unit and one for the caregivers so thatthere would be a standard practice of procedures for thestaff and caregivers to adhere to in order to avoidmiscommunication and inappropriate delivery of care.

DISCUSSION

HMV for patients with chronic respiratory failure hasbeen known to prolong survival17 and death will be

preventable with regular follow up for secondarycomplications; pressure ulcers, pneumonia andautonomic dysreflexia.18,19 Patients treated with bothinvasive and non invasive home mechanical ventilationreport reasonably good quality of lives.17 Long termfinancial burden is unavoidable though it would cost farless than nursing the patient in a hospital.20 Provision ofcare by immediate family members and friends maymarkedly reduce cost but can have other social,psychological and economic consequences.1 Patient andfamily experience stress when the home becomes a ‘hightech’ environment with the transference of hospitalroutine.21

CONCLUSION

Regular visits and follow up by the dischargeplanning team will enable the patient to live reasonablywell as the patient’s condition and skill adaptability ofcare giver can be assessed.16,22,23

Importance of good social support, guidance andcounseling has beneficial support for patient and theirrehabilitation.19 Being on HMV gives the patientautonomy, personal choice and treatments which werepreviously not possible in the past.24 There exists a lackof empirical evidence on the actual managed careprocess and preparing patients for mechanicalventilation at home is a new arena of nursing andmedical staff responsibility.1 The guideline drawn up forHMV for KPJ Johor Specialist Hospital was based onthe current practice of knowledge, its applicability andsuitability in a home environment.25

REFERENCES

1. Glass C, Grap MJ and Battle G (1999), Preparing the Patient andFamily for Home Mechanical Ventilation, MedSurg Nursing April1999.http://findarticles.com/p/articles/mi_m0FSS/isa_2_8/ai_n18608631 (Assessed online 6/4/2008).

2. Adams AB, Whitman J & Marcy t (1993), Surveys of long-termventilatory support in Minnesota: 1986 & 1992, Chest: TheCardiopulmonary Journal, 103, pp 1463-1469.

3. Lin MC, Huang CC, Lan RS & Tsai YH (1996), Homemechanical ventilation: Investigation of 34 cases in Taiwan.Chang I Hsueh,19, pp 42-49.

4. Litwin PD, Flegel CM & Richardson BG (1992), An overview ofhome mechanical ventilation in Canada, RRT: The CanadianJournal of Respiratory Therapy, 28 (2) pp 67-73.

5. Ledger P, Bedicam JM, Cornette A et al (1994), Nasal Intermittentpositive pressure ventilation in long term follow up in patientswith severe chronic respiratory insufficiency, Chest 1994; 105 : pp100-105.

6. Goldstein RS & Pierson DJ (1991), Long term mechanicalventilation as elective therapy. Respir Care 1991;36(4): pp 288-289.

7. AARC Clinical Practice Guideline (1995). Long Term InvasiveMechanical Ventilation in the Home, Respiratory Care1995;40(12): pp 1313-1320.http://www.rejournal.com/online_rsources/cpgs/himvcpg.html(Assessed online 31/2007)

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26 Nur Yasmin et al.

8. Donar ME (1988), Community Care: pediatric home mechanicalventilation, Holistic Nurse Pract 1988;2(2): pp 68-80.

9. Glass C (1998), Home Care management in ventilator assistedpatients in M.Chulay(ed), Research based practice protocols AlisoViejo CA: ACCN AARC Clinical Practice Guideline (1995).Providing Patient & Caregiver Training, Respiratory Care1996;41(7): pp 658-663.http://www.rejournal.com/online_rsources/cpgs/pcgtcpg.html(Assessed online 15/1/2007)

10. Gilmartin ME (1994). Transition from the intensive care unit tohome: patient selection and discharge planning, Respiratory Care1994;39(5): pp 456-480.

11. Muir JE & Cuvelier A (1995), Home Care of severe COPD,Revue du Practicien 45, pp 1251-1256.

12. McMillan SC, Mahon M (1994), The impact of hospice serviceson the quality of life of primary caregiver, Oncol Nurs Forum217(1994) pp 1189-1195.

13. KPJ Nursing Policies & Procedures (2004).14. AARC Clinical Practice Guideline (1995). Humidification during

mechanical ventilation, Respiratory Care 1992;37(8): pp 887-890.15. Fields AI, Rosenblatt A, Pollack MM, Kaufman J (1991), Home

care cost effectiveness for respiratory technology dependentchildren, AJDC 1991;145: pp 729-733.

16. Dellasega C, Clark D, McCreary D, Helmuth A, Schan P (1994),Nursing Process: teaching elderly clients, J gerontol Nurs1994;20(1): pp 31-38.

17. Siimonds AK (2003), Home Ventilation, Eur Rspir J 2003; 22, pp385-465.http://erj.ersjournals.com/cgi/content/full/22/47 suppl_/ 38S(Assessed online 24/3/2008)

18. Mckinley WO, Jackson AB, Cardenas DD & Devivo MJ (1999),Long Term Complications after Traumatic Spinal Cord Injury:Regional Model System Analysis. Archives of Physical medicine& Rehabilitation. Vol 80. Issue 11, Nov 1999 ppl 402-1410.http://www.sciencedirect.com.ezlibproxy.unisa.edu.au/science?ob=ArticleURL&_udi=B6WB6-4(assessedOnline 21/1/07)

19. Strauss D, Devivo MJ, Paculdo Dr, Shavelle RM (2006), Trendsin Life Expectancy after Spinal Cord Injury, Archives of PhysicalMedicine & Rehabilitation. Vol 87. Issue 8, August 2006. pp 1079-1085.http://www.sciencedirect.com.ezlibrpoxy.unisa.edu.au/science?ob=Article URL &_udi= B6WB6_4 (Assessed Online 21/1/09)

20. Goldberg AL & Frye (1990), The ventilator assisted individualstudy, Chest: The Cardiopulmonary Journal,98 pp 428-433.

21. Lindahl B,Sandman P-O,Rasmussen BH (2004), On becomingDependent on Home mechanical ventilation Issues andInnovations in Nursing Practice 2005 Blackwell Publishing Ltd.Journal of Advanced Nursing, 49 (1), 33-42.

22. Devivo MJ, Stover SL (1995), Long Term survival and causes ofdeath in SL Stover: Spinal cord injury clinical outcomes from themodel systems, Aspen, Gaithersberg (1995); pp 289-316. JADelisa & GG Whiteneck, EditorsDunne P (1994), Demographicsand financial impact of home respiratory care, Respir Care1994;39(4): pp 309-320.

23. Devivo MJ, Krause JS 7 Lammertse P (1999), Recent trends inmortality & causes of death among persons with spinal cordinjury, Archives of Physical Medicine & Rehabilitation Vol 80,Issue 11, Nov 1999, pp 1411 – 1419.http://www.sciencedirect.com.ezlibproxy.unisa.edu.au/science?_ob (Assessed on line 11/2/2007).

24. Sevick MA, Kamlet MS, Hoffman LA & Rawson I (1996),Economic cost of home based care for ventilator assistedindividuals: A preliminary report. Chest: The CardiopulmonaryJournal, 109(6), pp 1597-1606.

25. Abdullah NY (2007), Unpublished master of Nursing Project- ANurses Guide to Home Ventilation.

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KPJ Medical Journal 4:27–28 (2010) 27

CASE REPORTS

CASE REPORT

Mr KM was a 43 year-old man who presented to the Emergency Department, KPJ Damansara SpecialistHospital with chest discomfort, weakness of right side of the body and face, associated with "forgetfulness"which was sudden in onset, started on the day prior to his admission. His other concurrent medical problemswere Type II Diabetes Mellitus, Hypertension,Hyperlipidaemia, and he had undergone left kneearthroscopy three months prior to this admission,complicated by Staphylococcus aureus septic arthritiswhich had recovered one month ago.

On physical examination, he was normotensive, bloodglucose level was normal. He opened eyesspontaneously, but with conjugate deviation of both eyesto the right. He was unable to neither obey commandsnor vocalize. There was pallor with tinge of jaundice.There was a grade 3/5 weakness of the left upper andlower limbs. CT scan and MRI of the brain werereported as normal. Full blood count at presentationshowed severe anaemia (Hb7.5g/dL) withthrombocytopaenia (29x10^9/L) and normal WBCcount. Lactate dehydrogenase was elevated at 1105 u/L.Peripheral blood film demonstrated fragmented redblood cells and thrombocytopaenia consistent withmicroangiopathic haemolytic anaemia (Fig. 1). Coombs’test was negative.

ABSTRACTThombotic thrombocytopaenic purpura is a rare, serious but treatable clinical condition. It isimportant to recognise this condition early as prompt therapy results in better outcome. The earlyclues would be unexplained anaemia with thrombocytopenia in a young adult who presents withunexplained global neurological symptoms. The case illustrates a young male who wassuccessfully treated for this condition. KPJ Medical Journal 2010; 4:27–28

Key words : Thombotic thrombocytopaenic purpura.

Goh Kim Yen, MBBS, FRCP

A Case of Idiopathic Thrombotic ThrombotycopaenicPurpura Successfully Treated with Therapeutic

Plasma Exchange

Fig. 1. Blood film demonstrating fragmented red bloodcells and thrombocytopaenia consistent withmicroangiopathic haemolytic anaemia.

Correspondence: Goh Kim YenKPJ Ampang Puteri Specialist Hospital,1, Jalan Memanda 9, Taman Dato’Ahmad Razali,68000 Ampang, Selangor.

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He was subjected to a total of sixteen sessions oftherapeutic plasma exchange and after the thirteenth run,there was notable improvement in his mental alertnessand platelet counts, with resolution of left sidedhemiparesis (Fig. 2). He was discharged well after 4 weeks with complete resolution of neurological signsand near normal blood count profile.

DISCUSSION

Thombotic thrombocytopaenic purpura (TTP) is aclinical syndrome characterized by the pentad of fever, microangiopathic haemolytic anaemia,thrombocytopaenia, neurological impairment and renalimpairment.1 The pathological changes are due towidespread platelet microthrombi formation. Theunderlying etiology is due to presence of inhibitor of vonWillebrand Factor(vWF)-cleaving protease leading toincreased number of large vWF multimers in the bloodcirculation resulting in excessive platelet adhesion and aggregation.2 Hence, platelet transfusion iscontraindicated. There was no exact associationidentified in this case although it is commonly describedto be associated with pregnancy/post-partum, malignancy,sepsis, bone marrow transplantation, drugs etc. Thepresentation of this disease is usually abrupt.

The treatment of choice in this disease is therapeuticplasma exchange (TPE)3, to remove the large vWF multimers from the circulation. Patients usuallyrequire multiple sessions of TPE. Improvement can be gauged by improvement in neurological status,thrombocytopenia, and a reduction in lactatedehydrogenase. Other adjuvant and supportive measuresare instituted while waiting for recovery in the form of

red cell transfusion, haemodialysis, antiplatelet,anticonvulsant etc. The main problems encountered in the management of these patients are the requirementof central venous access in patients who arethrombocytopaenic and huge exposure to blood donorproducts with potential risk of blood-borne pathogentransmission.

The natural course of the disease can be either singleepisode, relapsing, chronic or refractory. Oral immuno-suppressants are occasionally given to prevent arecurrence of disease. The patient was given oralimmunosuppressant for a year and has remained wellsince discharge. It is important for practicing physicianto recognize this uncommon yet treatable disease. Thisdisease carries a mortality of over 50% in conservativelymanaged cases.

REFERENCES

1. Hoffbrand et al. Acquired Haemolytic Anaemia. PostgraduateHaematology, fourth edition, pp156-8.

2. Furlan el al. von Willebrand Factor-Cleaving Protease inThrombotic Thrombocytopenic Purpura and the HemolyticUremic Syndrome. N Engl J Med 339;1578-1584.

3. Pier Mannuccio Mannucci. How I Treat Patients with volWillebrand Disease. Blood Vol 97: pp1915-1919.

ACKNOWLEDGMENTS

1. Dr Daud Sulaiman, Consultant Cardiologist, KPJ DamansaraSpecialist Hospital, for giving the opportunity to share the care ofpatient KM.

2. Ms Zarina Zainal, IT Dept, KPJ Ampang Puteri SpecialistHospital, for her assistance with Fig. 2.

3. All staff from Nursing, Pharmacy, Laboratory & RadiologyDepartments for their direct and indirect care of this patient.

28 Goh Kim Yen

Fig. 2. Patient’s haemotological profile

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KPJ Medical Journal 4:29–30 (2010) 29

CASE REPORT

JK, is a 38 year-old lady who presented in July 2006,post-partum 2 months with right submadibular abscessand fever. She was noted earlier in February that year tohave leukocytosis but has declined further investigationin view of her pregnant state. She presented with severepancytopaenia. Haemoglobin level was 5.3g/dL, plateletcount of less than 10x10^3/uL and white blood cell count28.6x10^3/ul. Bone marrow examination confirmed acutemyeloid leukaemia, FAB subtypes AML-M6 with normalcytogenetics. She was given induction chemotherapyand followed by 2 more courses of post-remissionchemotherapy. She underwent allogeneic peripheralblood stem cell transplant in first complete remission onthe 18th of January 2007. She was given myeloablativedoses of Busulphan and Cyclophosphamide asconditioning regimen. Methotrexate and Cyclosporin Awere used as graft-versus-host disease (GVHD)prophylaxis. The donor was her fully HLA-matched 31year-old brother. The transplant period was uneventfuland she was discharged after four weeks ofhospitalization. Reassessment marrow examinationperformed at day 21 of transplant, on 8th of February2008 confirmed total engraftment of donor cells (100%46,XY) by Fluorescent-in-situ-hybridization method onnuclei isolated from bone marrow aspirate.

DISCUSSION

Acute myeloid leukaemia is a type of haematologicalmalignancy with an incidence rate of 1.8 per 100,000population.1 It is an aggressive and fatal disease in many.

Patients presenting under the age of 60 had an overall 5-year survival of 37%.2 The favorable prognosticfactors are young age at presentation, favorablecytogenetics, low presenting white blood cell counts andabsence of previous therapy and MyelodysplasticSyndrome. Hence cytogenetic analysis by karyotypingmethod is an important test at diagnosis. Studies havedemonstrated that stem cell transplantation results inbetter disease-free survival compared to intensiveconsolidation chemotherapy alone.3 It has been astandard practice to subject all patients with AML, withthe exception of AML FAB M3, to stem celltransplantation in first complete remission.

The introduction of granulocyte colony-stimulating-factor in the early 1990s has shifted the way stem cellsare collected from eligible donors from bone marrow toperipheral blood. This is by means of a cell separatormachine. The benefits of using peripheral blood stemcells (PBSC) are many folds mainly avoidance ofgeneral anaesthesia and faster engraftment of PBSCcompared to marrow stem cells. Faster engraftment will lead to lesser days with neutropenia andthrombocytopenia and further reduction in the morbidityand mortality associated with the procedure.

Unlike solid organ transplantation, stem celltransplantation not only changes the marrow constitutionto that of the donor’s, as in this case of sex-mismatchedtransplantation, the donor’s male cells now reside andproliferate in the marrow spaces of the female recipient.

ABSTRACTAcute myeloid leukaemia (AML) is a malignant white blood cell disorder, which carries a high rateof fatality if untreated. An allogeneic stem cell transplantation is indicated in all types of AML, withthe exception of acute promyelocytic leukaemia (FAB M3 subtype), once remission of disease isachieved. The case illustrates a successful stem cell transplantation procedure, utilising stemcells harvested from the peripheral blood, performed at KPJ Ampang Puteri Specialist Hospital.KPJ Medical Journal 2010; 4:29–30

Key words : Acute myeloid leukaemia, stem cell transplantation.

Goh Kim Yen, MBBS, FRCP

Peripheral Blood Stem Cell Transplant Procedurefor Acute Myeloid Leukaemia in

Complete Remission inKPJ Ampang Puteri Specialist Hospital

Correspondence: Goh Kim Yen,KPJ Ampang Puteri Specialist Hospital,1, Jalan Memanda 9, Taman Dato’Ahmad Razali,68000 Ampang, Selangor.

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In addition, there is also similar immune reconstitutionto that of the donor’s, hence immunosuppressive agentsfor the donors are for a limited period only anddifference in blood group is not a contraindication tostem cell transplantation.

It requires a team and multidisciplinary approach tomake stem cell transplant procedure available in aprivate hospital setting. Besides the requirement forreverse-isolation room with clean environment and goodair quality, the procedure is costly, requires a team ofdedicated staff particularly from the nursing andpharmacy department. It also imposes heavy load on thetransfusion unit for adequate and prompt blood productsupport.

REFERENCES

1. NCI SEER Program 1995-1999.2. Appelbaum et al. Acute Myeloid Leukemia. Hematology 2001

(1):62.3. Zittoun RA et al. Autologous or Allogeneic Bone Marrow

Transplantation compared with Intensive Chemotherapy in AcuteMyelogenous Leukemia. N Engl J Med 1995;332:217.

ACKNOWLEDGMENT

1. All staff, from Nursing, Pharmacy, Laboratory & RadiologyDepartments for their direct and indirect care of this patient.

30 Goh Kim Yen

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KPJ Medical Journal 4:31–32 (2010) 31

1Department of Otorhinolaryngology-Head & Neck Surgery,Hospital Tuanku Jaafar, Seremban, Negeri Sembilan.

2Ear, Nose & Throat-Head & Neck Consultant Clinic, SerembanSpecialist Hospital, Seremban, Negeri Sembilan.

3Department of Otorhinolaryngology-Head & Neck Surgery,Faculty of Medicine, Universiti Kebangsaan Malaysia.

Correspondence: Dr Primuharsa Putra Bin Sabir Husin Athar,MD (UKM), MSurg ORL-HNS (UKM), AM (Mal) Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Seremban Specialist Hospital,Suite 21-First Floor, Jalan Toman 1,Kemayan Square, Seremban,Negeri Sembilan Darul Khusus.E-mail: orlhns_kpjseremban@yahoo.com

ABSTRACTCastleman's disease is a rare, benign lymphoproliferative disorder of uncertain origin. It iscommonly found in the mediastinum. Extrathoracic site of the disease is uncommon. We report acase of unicentric Castleman's disease of the right parotid region in 60-year-old male without anyassociated systemic illness. KPJ Medical Journal 2010; 4:31–32

Key words : Castleman’s disease, parotid gland.

Gopalan KN, MD, MSurg ORL-HNS,1 Primuharsa Putra SHA, MD, MSurg ORL-HNS,2

Marina MB, MD, MSurg ORL-HNS,3 Mazita A, MBBCh BaO, MSurg ORL-HNS,3

and Valuyeetham KA, MBBS, MSurg ORL-HNS,1

Unicentric Castleman’s Disease of the Parotid

INTRODUCTION

Castleman’s disease (CD) is a benign lympho-proliferative disorder of unknown cause characterized byenlarged hyperplastic lymph nodes. The most commonsites of this lesion are the mediastinum, head and neck,cervical lymph nodes, axilla and the abdomen.1 Thoughthe head and neck is the second most common site,2,3

the involvement of the parotid gland is extremely rare.

CASE REPORT

A 60-year-old male presented with a painless swellingof the right parotid region of 6-years duration. Theswelling was progressively increasing in size. He had nofacial pain, facial asymmetry, weight loss or loss ofappetite. On examination, there was an oval shaped, firm,smooth surfaced and non tender swelling of the right infra – auricular region. Blood investigations revealednormal hemoglobin level and markedly raised ESR.

CT scan revealed two well defined lesionsrepresenting enlarged lymph nodes abutting the inferioraspect of the parotid gland (Fig. 1). Fine needleaspiration cytology revealed reactive lymphadenitis andinvestigations for tuberculosis were negative. A superficialparotidectomy was done for this patient and histologicalexamination revealed hyaline vascular-type Castleman’sdisease of the parotid gland (Fig. 2). Post-operativelypatient recovered uneventfully.

DISCUSSION

Castleman’s disease (CD) was first decribed byCastleman and colleagues in l956.4 It is also known asgiant lymph node hyperplasia, angiomatous lymph nodehamartoma, angiofollicular lymph node hyperplasia,follicular lymphoreticuloma and benign giantlymphoma.5,6

Fig. 1. Computed tomography showing enlarged lymphnodes abutting the inferior aspect of the right parotidgland.

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The pathogenesis of CD has not been elucidated.Some authors favour a theory of lympho-proliferationdue to chronic antigenic stimulation by a virus or chronicinflammation while others consider it to be a lymphoidhamartoma.7

CD is divided into two clinical subtypes: localized andmulticentic. Localized (or unicentric) disease manifestsas a solitary mass that may be well circumscribed orinfiltrative, with associated lymphadenopathy confinedto one lymph node or nodal area.8

Two histological subtypes are recognized: classichyaline vascular type which is usually unicentric, andplasma cell type which can be multifocal (multicentric)and associated with systemic symptoms. The hyalinevascular subtype is more common and containsnumerous regressively transformed follicles, withassociated vascular proliferation. In the head and neck,98% of these lesions are of the hyaline vascular type.9

Unicentric disease tends to occur in younger patientsand is hyaline vascular type in more than 70% of cases,with plasma cell or mixed histology in the remainder.10

The plasma cell type contains hyperplastic follicles, withmarked plasma cell proliferation in the interfollicularregions. Multicentric disease, commonly of the plasmacell type, usually follows an aggressive and rapidly fatalcourse.

Castleman’s disease often presents a diagnosticchallenge because of the paucity of signs and symptoms,lack of diagnostic tools and its tendency to mimicneoplasm.11 The definitive diagnosis is solelyestablished by histology analysis.

The treatment of localized Castleman's disease iscomplete surgical excision, with excellent long-termresults.10 This is almost always curative, resulting inrapid resolution of systemic symptoms and laboratoryabnormalities. Recurrence are rare in the hyalinevascular type. In patients with multicentric disease or inwhom complete resection is not possible, partialresection, radiotherapy, combination chemotherapy andanti-cytokine therapies have all been used, with variableresponses.12

CONCLUSIONAlthough rare in the head or neck region, Castleman'sdisease should be considered when investigating massesin these regions.

REFERENCES

1. Yi AY, deTar M, Becker TS, Rice DH. Giant lymph nodehyperplasia of head and neck (Castleman’s disease): a report offive cases. Otolaryngol Head Neck Surg 1995; 113: 462-6.

2. Nahlieli O, Hasson O, Ben-Dor D, Goupil MT. Rapidly growingmass in the parotid gland. J Oral Maxillofac Surg 2000; 58: 552-6.

3. Goodisson DW, Carr RJ, StirlingRW. Parotid presentation ofCastleman’s disease: report of a case. J Oral Maxillofac Surg1997;56:515-7.

4. Castleman B, Iverson L, Mendez VP. Localized mediastinallymph nodes hyperplasia resembling thymoma. Cancer1956;9:822-30.

5. Zim S, Doherty J, Ma Y, Lee E. Pathology quiz case. Castleman’sdisease (CD), unicentric, hyaline vascular type. Arch OtolaryngolHead Neck Surg 2001;127:1133-5.

6. Gaba AR, Stein RS, Sweet DL, Variakojis D. Multicentric giantlymph node hyperplasia. Am J Clin Pathol 1978;69:86-90.

7. Lanier BJ, Cummings CW. Giant lymph node hyperplasiapresenting as a vascularized parapharyngeal mass. OtolaryngolHead Neck Surg 1982;90:426-30.

8. Bowne WB, Lewis JJ, Filippa DA, Niesvizky R, Brooks AD, BurtME, Brennan MF. The management of unicentric and multicentricCastleman’s disease: a report of 16 cases and a review of theliterature. Cancer 1999;85:706-17.

9. Samadi DS, Hockstein NG, Tom LW. Pediatric intraparotidCastleman’s disease. Ann Otol Rhinol Laryngol 2003;112:813-6.

10. Parez N, Bader-Meunier B, Roy CC, Dommergues JP. PaediatricCastleman’s disease: report of seven cases and review of theliterature. Eur J Pediatr 1999;158:631-7.

11. Panayiotides J, Tsilalis T, Bollas N, Karameris A. ParotidCastleman’s disease. Cytopathology 1998;9:50-4.

12. Nishimoto N, Sasai M, Shima Y, Nakagawa M, Matsumoto T,Shirai T, Kishimoto T, Yoshizaki K. Improvement in Castleman’sdisease by humanized anti-interleukin-6 receptor antibodytherapy. Blood 2000;95:56-61.

32 Gopalan KN et al.

Fig. 2. Section showing lymphoid follicles withpostcapillary venules surrounded by fibrocollagen(features of Castleman’s disease).

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KPJ Medical Journal 4:33–34 (2010) 33

INTRODUCTION

Cat-scratch disease (CSD) is a common, self-limitingdisease process. Patients with CSD generally presentwith regional lymphadenopathy after a cat scratch or bitedistal to the involved lymph node. The accuratediagnosis of CSD based on clinical and histopathologicalfindings. CSD can cause a very diverse and fascinatingarray of clinical syndromes and is capable of affectingorgans other than skin and lymph nodes.1 These atypicalmanifestations, together with serious complications,usually occur more often in the pediatric population andalso in immunocompromised hosts.2 Although largeseries of patients with cat-scratch disease have beendetailed in the literature,3,4 involvement of the parotidparenchyma is rare.3,5

CASE REPORT

A 14-year-old Malay boy presented with history ofswelling of the right parotid area for 5 days. There wasno history of pain, fever or any symptoms during meals.There was no significant past medical of family history.Examination revealed right parotid swelling, measuring2 x 2 cm, non tender,firm and mobile. There was no signof inflammation and other swellings were felt in theneck. Throat examination was normal and facial nervewas intact. Total white blood count was 6.9 x 103 / L anderythrocyte sedimentation rate was 44 mm/h. Ultrasoundand CT scan of the parotid area showed a well defined 2 x 2.3 cm soft tissue mass within the superficial lobe ofthe right parotid gland and there was no enlargedcervical nodes. Fine needle aspiration cytology of the parotid swelling reported to be suggestive of a malignant lymphoid pathology. An excision biopsy wasadvised by the pathologist. He then underwentsuperficial parotidectomy with facial nerve preservation.Intraoperatively, there was well-encapsulated tumourmeasuring 2 x 3 cm and multiple intraparotid lymph

nodes. All the lymph nodes were dissected out. Post-operatively transient right facial nerve paresis was noted.Histopathological examination of both the parotidtumour and cervical lymph nodes showed features ofchronic granulomatous inflammation consistent withcat-scratch disease. Upon inquiry, the boy confirmedhaving cats at home and frequently plays with them. Onfollow up at six weeks, he was well. Facial nerve wasnormal and no recurrence of parotid swelling.

DISCUSSION

Bartonella henselae, a pleomorphic gram-negativerod is the causative agent for the well-recognized,benign, and self-limited cause of lymphadenitis inchildren referred to as cat-scratch disease (CSD). B henselae usually originates from infected kittens and istransmitted through a scratch or break in the skin6 that isoften recalled only in retrospect as shown in our case. Ina small percentage of patients with cat scratch diseasethere is no history of contact with animals.6,7 Thecommon flea is usually the vector of transmission.8

ABSTRACTCat-scratch disease of the parotid gland is rare. We report a case of cat-scratch disease of theparotid gland in a 14-year-old boy. Cat-scratch disease was not considered in the initial diagnosisof this patient. Superficial parotidectomy was performed based on initial FNAC which wassuggestive of a malignant lymphoid pathology. Post-operatively, histological examinationconfirmed the diagnosis of cat-scratch disease. KPJ Medical Journal 2010; 4:33–34

Key words : Cat-scratch disease, parotid swelling.

Primuharsa Putra SHA, MD, MSurg ORL-HNS,1 Marina MB, MD, MSurg ORL-HNS,2

Razif MY, MBBS, MSurg ORL-HNS,2 and Tang MK, FRCS, MSurg3

Cat-scratch Disease Presenting as Parotid Mass

1Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Seremban Specialist Hospital, Seremban.

2Department of Otorhinolaryngology-Head & Neck Surgery,Faculty of Medicine, Universiti Kebangsaan Malaysia.

3Surgical Clinic, KPJ Seremban Specialist Hospital,Seremban, Negeri Sembilan.

Correspondence: Dr Primuharsa Putra Bin Sabir Husin Athar,MD (UKM), MSurg ORL-HNS (UKM), AM (Mal) Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Seremban Specialist Hospital,Suite 21-First Floor, Jalan Toman 1,Kemayan Square, Seremban,Negeri Sembilan Darul Khusus.E-mail: orlhns_kpjseremban@yahoo.com

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The accurate diagnosis of cat-scratch disease based onclinical and histopathological findings. Clinicalpresentation and physical examination findings providepertinent information in accurately diagnosing CSD, bydoing so, preventing unnecessary surgery and risk to thepatient. The standard for diagnosis includes three of thefollowing four diagnostic criteria: lymphadenopathy(localized or regional), recent cat contact, inoculationsite identification, and positive enzyme-linkedimmunosorbent assay (ELISA) or indirect fluorescenceantibody (IFA) studies.9 ELISA and IFA for detection ofserum antibody to antigens of B henselae are the mostaccurate diagnostic test and the most widely used test toconfirm the diagnosis of CSD.10 A single elevatedantibody titer is sufficient to confirm the diagnosis,because the humoral immune response precedes or isconcurrent with symptom onset.11 Cat scratch diseasemay be more prevalent than realised, and an unnecessarybiopsy may be avoided on the basis of serology results.12

In certain cases biopsy and histopathatologicalexamination are required to confirm the diagnosis and torule out malignancy.

Surgical excision is the most common diagnosticmeasure and is often also therapeutic. Standard CSDtreatment does not exist. The treatment depends on thepresentation and individualize to the presenting case andpatient's age. Treatment consist mainly of supportivetherapy and reassurance.13 No antimicrobial therapy isrequired in the majority of cases of cat scratch disease,since adenopathy is usually self-limited.14 However, anatypical presentation may require antibiotic therapy. Theuse of antibiotics in cat scratch disease withlymphadenopathy and no systemic symptoms remainscontroversial, although some benefit in the reduction oflymph node size has been shown with azithromycin.15

Steroids have not been shown to be effective.16

REFERENCES

1. Thurnheer U, Wiprachtiger U. Katzenkratzkrankheit. SchweizRundsch Med Prax 1995;84:122-6.

2. Shinall EA. Cat-scratch disease: a review of the literature. PediatrDermatol 1990;7:11-8.

3. Margileth AM. Cat scratch disease: nonbacterial regionallymphadenitis. The study of 145 patients and a review of theliterature. Pediatrics 1968;42:803-18.

4. Margileth AM. Cat scratch disease in 65 patients: evaluation of catscratch skin test antigens in 109 subjects. Clin Proc Child HospDist Columbia 1971;27: 213-23.

5. Travis LW, Hecht DW. Acute and chronic inflammatory diseasesof the salivary glands: diagnosis and management. OtolaryngolClin North Am 1977;10:329-38.

6. Carithers HA. Cat-scratch disease: An overview based on a studyof 1,200 patients. Am J Dis Child 1985;139(11):1124-33.

7. Daniels WB, MacMurray FG. Cat scratch disease: report of onehundred and sixty cases. JAMA 1954; 154:1247-51.

8. Chomel, BB, Kasten, RW, Floyd-Hawkins K, et al.: Experimentaltransmission of Bartonella henselae by the cat flea. J ClinMicrobiol 1996;34(8):1952-5.

9. Jameson P, Green C, Regnery R, et al: Prevalence of Bartonellahenselae antibodies in pet cats throughout regions of NorthAmerica. J Infect Dis 1995;172(10):1145-9.

10. Shenep JL: Cat-scratch disease and Bartonella henselae infectionsin children. Pediatr Ann 1996;25(9):518-23.

11. Dalton MJ, Robinson LE, Coper J, et al. Use of Bartonellaantigens for serologic diagnosis of cat-scratch disease at anational referral center. Arch Intern Med 1995;155:1670-6

12. Williams A, Sheldon CD, Riordan T. Cat scratch disease. BMJ2002;324:1199-200.

13. MalatskeyS et al. Cat-scratch disease of the parotid gland:an often –misdiagnosed entity. Ann Otol Rhinol Laryngol 2000;109:679-82.

14. Margileth AM. Cat scratch disease. Adv Pediatr Infect Dis1993;8:1-21.

15. Bass JW, Freitas BC, Sisier CL, Chan DS, Vincent JM, et al.Prospective randomised double blind placebo controlledevaluation azithromycin for treatment of cat scratch disease. PedrInfect Dis J 1998; 17: 447-52.

16. Carithers HA, Carithers CM, Edwards RO Jr. Cat-scratch disease.Its natural history. JAMA 1969;207: 312-6.

34 Primuharsa Putra et al.

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KPJ Medical Journal 4:35–36 (2010) 35

INTRODUCTION

The platysma myocutaneous flap (PMF) is seldomused for oral cavity reconstruction, as the radial forearmfree is favored by most head & neck surgeons. However,there are several reasons why this flap should remain inour armamentarium of reconstructive options. The(PMF) is thin, pliable and reliable. The color match tofacial skin, easy and time saving harvest. The donor sitecan be closed primarily with minimal morbidity.Additionally, microvascular surgeons are often unwillingor unavailable to perform free tissue transfer.

MATERIAL AND METHODS

From 2001-2004, 4 patients (Table 1) received aplatysma myocutaneous flap in a single stage primaryprocedure at Department of Otorhinolaryngology-Head& Neck Surgery, Faculty of Medicine/ HospitalUniversiti Kebangsaan Malaysia. The patients consistedof 3 male and 1 female, with the age range between 21 and 65 years. All patients had squamous cellcarcinoma of the lateral border of tongue, with tumorsize ranged from T2-T4 and their nodal status rangedfrom NO to N3. None of the cases had undergonepreoperative radiotherapy. All patients hadhemiglossectomy combined with either radical ormodified neck dissection. In all cases the resectionmargins were at least 2 cm from tumour and allintraoperative frozen section reported as all margins areclear. In three of the cases midline mandibulotomy wasperformed to facilitate reconstruction. Facial artery wasidentified and preserved in 3 cases.

RESULTS

All subjects were eventually able to begin oral feedingwithin 4 to 5 weeks and were able to communicateverbally with only minor difficulty. Only one patientdeveloped a fistula which was succesfully treatedconservatively for 2 weeks. None of the cases developedflap necrosis. Average hospital stay ranged from 11 to 16days. There were no returns to the operating room orneed for additional reconstruction. All subjects wasgiven a course of radiotherapy postoperatively. One casehad residual tumour and 1 had recurrence 9 months aftersurgery despite radiotherapy treatment. The other 2 caseswere well and had no recurrence after 16 and 12 months.

ABSTRACTA retrospective analysis of our experience with 4 patients who received a platysmamyocutaneous flap for reconstruction of tongue defects is presented. All patients had squamouscell carcinoma of the tongue, with tumour size ranged from T2 to T4 and their nodal status rangedfrom NO to N3 . Intraoperatively, 3 patients had facial artery preservation and 1 patient hadligation of the facial artery. The average hospital stay was 11-16 days. There was 1 flap-relatedcomplications-fistula formation. This fistula resolved with local care only. Their speech andswallowing function was fairly good. Adjuvant postoperative radiotherapy was given to 3 patients.These results indicate that the platysma myocutaneous flap is an excellent reconstructive optionfor oral cavity defects. KPJ Medical Journal 2010; 4:35–36

Key words : Platysma myocutaneous flap, tongue reconstruction.

Primuharsa Putra SHA, MD, MSurg ORL-HNS,1 Marina MB, MD, MSurg ORL-HNS,2

Roszalina R, FDSRCS, FFDRCS,3 and Ridzo Mahmud, MSurg ORL-HNS, FRCS4

Platysma Flap in Oral Cavity Reconstruction

1Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Seremban Specialist Hospital, Seremban, Negeri Sembilan.

2Department of Otorhinolaryngology-Head & Neck Surgery,Faculty of Medicine, Universiti Kebangsaan Malaysia.

3Department of Oral & Maxillofacial Surgery,Faculty of Dentistry, Universiti Kebangsaan Malaysia.

4Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Johor Specialist Hospital, Johor Bahru, Johor.

Correspondence: Dr Primuharsa Putra Bin Sabir Husin Athar,MD (UKM), MSurg ORL-HNS (UKM), AM (Mal) Ear, Nose & Throat-Head & Neck Consultant Clinic,KPJ Seremban Specialist Hospital,Suite 21-First Floor, Jalan Toman 1,Kemayan Square, Seremban,Negeri Sembilan Darul Khusus.E-mail: orlhns_kpjseremban@yahoo.com

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DISCUSSION

The platysma is a thin broad sheet of muscle investingthe anteromedial aspect of the neck. Its originates fromthe fascia over the upper parts of the pectoralis major anddeltoid muscles. It inserts into the skin and subcutaneoustissues of the lower face.

The submental artery which is a branch of the facialartery was the primary vessel to the platysma.1 Thesubmental artery flap can be dissected to the facial arteryand that this flap also can be based superiorly orinferiorly because of the rich collateral circulation in thehead and neck, thereby extending the length of thepedicle and hence the reach of this flap.2 Previous reportstated that an intact facial artery is crucial to assure flapsurvival. We had ligated facial artery in one of ourpatient and we did not encounter any problem. Huwirtzet al performeda detailed study of the blood supply of theplatysma muscle and found that an intact facial artery isnot crucial to the survival of the flap.3 This conclusionwas supported by others.4,5

Platysma flaps have many advantages. The thinnessand pliability of the muscle and skin paddle make it idealfor all positions in the oral cavity, where avoidance ofexcessive bulk is desirable, particularly in the floor of themouth and gum regions. There is negligible functionalimpairment of deglutition, speech, and denture fitting.5

It can be harvested with enough tissue to close most head& neck ablative defects (at least 70 cm2).6 There isvirtually no donor site morbidity involved. No specialspecial skill, equipment, or technique is required forplatysma flap design and harvest.4,5,6,7 The disadvantagesof platysma flaps are relatively few. The reach and tissuebulk provided are limited.

Reported contraindications to the use of the platysmamyocutaneous flap have included prior neck dissectionand preoperative irradiation.8,9,10 None of our patient hadpreoperative irradiation. No adverse effect could bedemonstrated by administration of preoperativechemotherapy.5 Large tumour size or invasion ofadjacent structures was not a contraindication to the useof the platysma myocutaneous flap.5 A lip-splittingextension of the apron incision, segmental or marginal

mandibulectomy also can be used if required for tumourresection without jeopardizing the vascularity of the flap.5

Among complications reported in the literature arepartial flap necrosis involving the epithelium alone,skinnecrosis of the neck suture line, and fistula formation.5,6

Most of the complications resolved with local care only.

CONCLUSION

The platysma flap is an excellent reconstructiveoption for oral cavity defects. Our result shows thereliability and versatility of the platysma flap andindicates that the flap can be used without significantmorbidity.

REFERENCES

1. Uehara M, Helman JI, Lillie JH, Brooks SL. Blood supply to theplatysma muscle flap: An anatomic study with clinicalcorrelation. J Oral Maxillofac Surg 2001; 59(6): 642-6.

2. Martin D, Pascal JF, Baudet J, et al. The submental island flap: Anew donor site. Anatomy and clinical applications as a free orpedicled flap. Plast Reconstr Surg 1996; 92:867.

3. Hurwitz DJ, Rabson JA, Futrell JW. The anatomic basis for theplatysma skin flap. Plast Reconstr Surg 1983; 72: 302-14.

4. McGuirt WF, Matthews BL, Brody JA, May JS. Platysmamyocutaneous flap: caveats reexamined. Laryngoscope 1991;101: 1238-44.

5. Ruark DS, McClairen WC Jr, Schlehaider UK, Abdel-Misih RZ.Head and neck reconstruction using the platysma myocutaneousflap. Am J Surg 1993; 165(6):713-8.

6. Koch WM. The platysma myocutaneous flap: UnderusedAlternative for head and neck reconstruction. Laryngoscope2002; 112(7):1204-8.

7. Esclamado RM, Burkey BB, Carroll WR, Bradford CR. Theplastyma myocutaneous flap. Indications and caveats. ArchOtolaryngol Head Neck Surg 1994; 120(1):32-5.

8. Conley JJ, Lanier DM, Tinsley P Jr. Platysma myocutaneous flaprevisited. ArchOtolaryngol Head Neck Surg 1986;112(7):711-3.

9. Persky MS, Kaufman D, Cohen NL. Platysma myocutaneous flapfor intraoral defects. Arch Otolaryngol 1983;109(7):463-4.

10. Cannon CR, Johns ME, Atkins JP Jr, et al. Reconstruction of theoral cavity using the platysma myocutaneous flap. ArchOtolaryngol 1982;108(8):491-4.

36 Primuharsa Putra et al.

Table 1—Patient characteristics

Case Age Sex Race Stage Site Treatment

1 65 M Malay T4N3MO Lateral border, Hemiglossectomy, right radicalright tongue and left supraomohyoid

neck dissection2 36 M Chinese T3N2aMx Lateral border, Hemiglossectomy, left modified

left tongue radical and right supraomohyoidneck dissection

3 21 F Malay T4N2cMx Lateral border, Hemiglossectomy, bilateralleft tongue modified radical neck dissection

4 38 M Chinese T2NOMO Lateral border, Hemiglossectomy, rightright tongue modified neck dissection

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KPJ Medical Journal 4:37–40 (2010) 37

INTRODUCTION

Despite rapid advances in medical technology, feverof unknown origin (FUO) continues to remain a majorproblem in Medicine. Amongst its numerous causes,Adult-onset Still’s disease (AOSD) tends to tax theclinician’s ingenuity to diagnose the syndrome asillustrated by the patient presented here.

CASE REPORT

A 29-year old police officer was admitted to the centrein September 2005 with fever and joint pains.

She was well till three months prior to admissionwhen she developed fever and multiple joint pains. Thefever was intermittent and was associated withconstitutional symptoms. There was some undocumentedweight loss. She had earlier consulted several generalpractitioners and was treated symptomatically. A monthearlier she was admitted to another hospital for twoweeks and was discharged home without specificconclusions.

During her present admission she was febrile with thetemperature spiking to 39-40ºC on and off in the ward.She appeared relatively well in between her febrileepisodes. The proximal interphalangeal (PIP) and wristjoints were swollen and tender. The physicalexamination was otherwise unremarkable.

The results of the routine blood counts, liver functiontests, creatine kinase (CK) and lactate dehydrogenase(LDH) are shown in Table I. Blood culture was negative.The x-rays of the hands and chest were also normal. Therheumatoid factor, anti-nuclear factor, thyroid functiontests, renal and lipid profiles as well as urinalysis wereeither normal or negative. She tested negative for human

immunodeficiency virus infection. Hepatitis panelincluding B and C was negative. Venereal DiseaseResearch Laboratory (VDRL) test was also negative.

She was treated symptomatically with diclofenecsodium while waiting for her septic workout to return.On the second day into admission, prednisolone wasprescribed as her joint pain was rather excruciating. Shefelt well two days later and insisted on discharge fromthe centre but promised to return for review in the clinic.She did not do so.

She was readmitted to the centre a month later. Sheagain complained of fever on and off for ten days. Herjoint pain too had recurred. During this admission herknees and elbows too were involved. At the same timeshe was noted to have a transient rash over her anteriorabdominal wall and arms. The rash was not itchy and thepatient was not really concerned.

The clinical examination was almost identical to herearlier admission except for mild effusion into her knees.On closer examination even though the patient was ofdarker complexion, the rash was found to be the classicalevanescent rash one sees in patients with Still’s disease.

Table 1 shows some of the routine blood counts done.Besides, the septic workout was again negative. The anti-nuclear factor, extractable nuclear antigens and therheumatoid factors were negative. C - reactive proteinwas markedly high at 94.9 mg/L (Normal: <1.0).

ABSTRACTThis report deals with a young woman with persistent fever whose cause remained elusive for along time. By exclusion she was found to suffer from Adult-onset Still’s Disease (AOSD). She responded well to appropriate therapy but her fever returned whenever she defaulted follow-ups! The report highlights some of the difficulties encountered in making the diagnosis ofAOSD as there are no specific pathognomonic features of the syndrome. KPJ Medical Journal2010; 4:37–40

Key words : pyrexia of unknown origin, Still’s rash, poyarthritis, hyperferritinaemia.

Ramanathan M, MBBS, FRCP

Fever of Unknown Origin:Consider Adult Onset Still’s Disease

Correspondence: Dr. M. Ramanathan,Consultant PhysicianTaiping Medical Centre,45-49 Jalan Medan Taiping 2,Medan Taiping,34000 Taiping, Perak.(E-mail: mraman@pc.jaring.my)

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Based on her clinical features and review of thelaboratory evaluations done earlier and the currentadmission she was diagnosed as a case of AOSD. Shewas treated with indomethacin, prednisolone,hydroxychloroquine, methotrexate (MTX) and folic acidsupplement. She had prompt response to the treatmentand was discharged from the centre a week later. Shereturned for review two weeks later. She was well.Steroids were stopped. She was asked to continue herhydroxycholoroquine and take the indomethacin on aprn basis. She was subsequently lost to follow-ups.

She was readmitted for the third time almost sevenmonths later in May 2006. She was very ill and appearedcachexic. She could not even speak because of pain inher temporomandibular joints. The history was from hermother. She was well for a short while after she stoppedher medications. She was then transferred to anotherstate. There her fever and joint pain recurred. She wasadmitted to a tertiary care hospital for further evaluation.She was in the hospital for about three weeks where sheunderwent several tests by different specialties. She wasadvised on the need for bone marrow and liver biopsy atthat hospital; both of which she refused. She thendischarged herself against medical advice to consulttraditional healers. As her condition deteriorated after aweek at home she was brought to the centre.

She had marked tenderness and mild swelling of herPIP, wrists, knees and elbows. Temperature was 40ºC.

The classical rash was again seen. Besides she alsocomplained of right chest pain which was pleuritic innature. She was also very irritable and insisted ontreatment without waiting for even the routine bloodtests to return. Table 1 shows some of the blood testsdone during this admission. The septic workout wasagain negative.

She was started on a three day pulse therapy of IVmethylprednisolone at 1gm daily. She was in additionstarted on MTX, hydroxychloroquine and folic acidsupplements.

She was well two days later. She then produced asummary of the various tests done at the previoushospital. The routine blood counts were almost similar towhat we had recorded here especially her total white cellcounts, platelets and ESR were high. Besides an entireseptic workout including several blood cultures wasnegative. The lupus screening was also negative. Thechest x-ray, ultrasound of the abdomen, computedtomographic scan of the abdomen and chest were alsonormal. A transthoracic (TTE) as well as a trans-oesophageal echocardiograms (TEE) were also normal.

She was discharged from the center after a week. Shewas seen regularly in the clinic for almost six months.The steroids were tapered off. She was continued onweekly MTX, hydroxycholoroquine and folic acidsupplements. She then defaulted!

38 Ramanathan M

Table 1—Laboratory results

Date/Test 09/2005 10/2005 05/2006 Normal values(where applicable)

Haemoglobin 102 g/L 98 g/L 86 g/L 115-165

White cell count 14.8 x 109 /L 11.5 x 109/L 16.4 x 109/L 4.0-11.0

Differential count Neutrophils83%, N80%, L 16%,M 4% N 88% L 8% M 4%Lymphocytes 14%Monocytes 3%

Platelets 453 x 10 9 /L 470 x 10 9/L 653 x109/L 150-450

ESR 130 mm/hour 131 mm/hour > 140 mm/hour < 21

Peripheral blood film Normal. Normal. Normal. Normal.

Liver Function:Total Protein 81 g/L Not available 80 g/L 60-82

Albumin 36 g/L Not available 29 g/L 35-50

Globulin 45 g/L Not available 51g/L 20-39

Alkaline Phosphatase 133 U/L Not available 126 U/L 30-120

Total Bilirubin 8 umol/L Not available 7 umol/L ,21

AST 51 U/L Not available 62 U/L <41

ALT 52 U/L Not available 22 U/L <51

Creatine kinase (CK) 19 U/L Not available Not available < 201

LDH 353 U/L Not available 348 110=240

Ferritin Not available 3628ug/L 2971ug/L 10-120

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Fever of Unknown Origin: Consider Adult Onset Still’s Disease 39

DISCUSSION

The concept of FUO was first introduced by Petersdorfand Beeson in 1961.1 They defined FUO as fever ofmore than 38.3ºC on several occasions lasting more than3 weeks for which a cause remained elusive after a weekof investigations. The original definition has undergonesome modifications. It is now an accepted practice tocarry out the initial investigations in an out-patient clinic.Debate however still continues as to what should be theminimum level of investigations required before labelinga particular patient as a case of FUO.2

Amongst the numerous causes of FUO, AOSD hassome very unique features. AOSD first described by EricBywaters in 1971.3 It is a rare systemic inflammatorydisorder of unknown aetiology. AOSD is a diagnosis ofexclusion. There are no specific clinical or laboratoryfindings which can conclusively point towards thediagnosis. Diagnosis can thus be easily missed .This hasled several workers to propose clinical and laboratorycriteria to be met with before arriving at the diagnosis ofAOSD4 (Fig. 1). Our patient illustrates some of theproblems one encounters in diagnosing AOSD.

Although our patient ultimately met with most of thecriteria for AOSD one cannot expect to see the entireclinical expression of AOSD during a single febrileepisode.5 Our patient’s tendency to default as well askeep changing her physicians posed problems incollecting the necessary historical data to diagnoseAOSD. One usually generates a gamut of possibilities ina particular case before confirming AOSD. Fig. 2 showsthe various diagnostic possibilities considered in thispatient.

The initial clinical impression in this patient was oneof either rheumatoid arthritis or acute rheumatic fever.Both the possibilities were excluded only on reviewingthe subsequent clinical and laboratory findings. Theclassical evanescent rash was only noted during her

Fig. 2. Diagnostic possibilities considered in this patient

Major:1. Arthralgia > 2 weeks.2. Fever > 39º C;intermittent,>1 week.3. Typical rash4. WBC> 10,000 (>80% granulocytes)

Minor:1. Sore throat.2. Lymphadenopathy and/or 3. splenomegaly.4. LFT abnormal5. (-)ve ANA and RF.

Diagnostic combinationExclusion criteria

1. Infections2. Malignancies.3. Rheumatic diseases.

Diagnosis:5 criteria (at least 2 major).

second admission. Even then the rash could have beeneasily dismissed as a drug reaction!

The excellent clinical and laboratory summaryprovided by the other hospital was very helpful inexcluding some of the common causes of FUO includinginfective endocarditis, lymphoma intrabdominal abscessand tuberculosis. Serological markers were repeatedlynegative for lupus.

The only possibility left on the slate was AOSD. Ourpatient met with almost all of the proposed criteria forAOSD. In addition her ferritin level was very high onboth the occasions it was done. Hyperferritinaemia hasbeen reported in more than 90% of cases of AOSD. Atthe moment raised serum ferritin level is not a requisitefor the diagnosis of AOSD. In view of no other specificor sensitive test for AOSD, some workers recommendthat hyperferritinaemia should be considered as animportant diagnostic and disease activity marker inAOSD.6,7,8

Further the persistent thrombocytosis, raised ESR andthe pleuritic pain she had during her last admission havebeen reported in patients with AOSD.7,8

Treatment strategies in ASOD have been mainlyempirical in nature. The rarity, heterogeneity and thedifficulty in diagnosing early AOSD have preventedfrom initiating prospective controlled treatment trials toprovide evidence based approach to its treatment.Current therapeutic strategies are based on case reportsand retrospective studies of small case series.7,8,9

Nonsteroidal anti-inflammatory agents (NSAIDS)with glucocorticoids have been the mainstay oftreatment. NSAIDS are useful in mild self limiting groupof patients. The next step on the treatment ladder is thedisease modifying antirheumatic drugs (DMARD),especially MTX. About 70% of patients have beenreported to benefit fully or partly from MTX.8

The patient under discussion was on steroids duringall her admissions. Almost all AOSD patients have beenknown to require steroids at some point in the course oftheir illness. While steroids are certainly useful, theirside effects in the long term administration cannot beignored. These agents are particularly known to causejoint destruction in AOSD.7,8

The field is open for patients who are refractory to NSAIDS and DMARD. The drugs advocated

1. Rheumatoid arthritis.

2. Rheumatic fever.

3. Systemic Lupus Erythamatosis.

4. Adult-onset Still’s disease.

5. Lymphoma.

6. Infective Endocarditis.

7. Intraabdominal abscess.

8. Tuberculosis.

Fig. 1. Diagnostic criteria for AOSD4

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40 Ramanathan M

for these patients include immunosuppressans, humanimmunoglobulin (IVIg), lefunomide and anti-TNFagents like infliximab and etancercept. Another drug thathas been reported to be promising is the ILI blocker,anakinra.7,8,9

CONCLUSION

The take home point for the clinician is until definiteevidence based guidelines are available; AOSD patientsshould initially be tried on NSAIDS, steroids andDMARD. If these modalities fail, then one might chooseone of the above mentioned drugs taking intoconsideration the availability, familiarity, side effectprofiles and cost of the agent chosen.

Prognosis is variable in AOSD. Three distinct patternshave been recognized.8 Some patients tend to go intoactive remission within a year. The second category ofpatients tends to have a polycyclic or intermittentsystemic pattern with flares on and off. The last group ofpatients has chronic joint problems. They are prone tojoint destruction and 67% of this group went throughjoint replacement in at least one joint after a mean of 28 months from the time of diagnosis.10

The patient under discussion when last reviewed wasthought to fall into the second group. But as she has not

come for any follow up for almost two years now it isdifficult to spell out the exact prognosis in her.

REFERENCES

1. Petersdorf RG, Beeson PB. Fever of unexplained origin: report on100 cases. Medicine(Baltimore). 1961; 40: 1-30.

2. Mourad O, Palda V, Detsky AS. A comprehensive evidence- basedapproach to fever of unknown origin. Arch Intern Med.2003;163:545-551.

3. Bywaters EGL. Still’s disease in adult. Ann.Rheum.Dis. 1971;30:121-33.

4. Yamaguchi M, Ohta A, Tsunematsu T, et al. Preliminary criteriafor classification of adult Still’s disease. J Rheumatol. 1992; 19:424-30.

5. Bujak JS, Aptekar RG, Decker JL, et al. Juvenile rheumatoidarthritis presenting in the adult as fever of unknown origin.Medicine 1973; 52: 431-44.

6. Meijvis SCA, Endeman H, Geers A B M et al. Exteremely highserum ferritin levels as diagnostic tool in adult-onset Still’sdisease. Nethr J Med. 2007; 65: 212-14.

7. Efthimiou P, Georgy S. Pathogenesis and management of adult-onset Still’s disease. Semin Arthritis Rheum 2006; 36: 144-52.

8. Efthimiou P, Paik PK, Bielory L. Diagnosis and management ofadult onset Still’s disease. Ann Rheum Dis.2006; 65: 564-72.

9. Pouchot J. Editorial: How can we improve the management ofadult-onset Still’s disease? Joint Bone Spine. 2007; 74: 117-119.

10. Wouters JM, van de Putte LB. Adult-onset Still’s disease; clinicaland laboratory features, treatment and prognosisof 45 cases. Q JMed 1986;61: 1055-65.

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KPJ Medical Journal 4:41–43 (2010) 41

infection, namely high grade fever, sore throat, cough,difficulty breathing, headache and myalgia.

Infants may present to the health care worker (HCW)with fever and lethargy, maybe poor feeding and diarrheaand vomiting (acute gastroenteritis being a morecommon explanation) and no other symptoms or signsrelated to the respiratory tract. A high index of suspicionis required to make the diagnosis especially if there is atravel history or contact with a case. Interestingly, 25%in the American and 14% in the European cohort ofInfluenza A patients had symptoms (diarrhea andvomiting) related to the gastro-intestinal tract which isnot typically found in seasonal influenza.

Unless early diagnosis is made, the child maydeteriorate with symptoms and signs of severe diseasewhich includes; cessation of breathing, rapid breathing,difficulty breathing, turning blue, dehydration, alteredconsciousness and irritability.

RISK FACTORS FOR SEVERE MORBIDITY ORMORTALITY

A subset of children who are at an even higher risk ofinfluenza related complications includes the following:

a. Less than 2 years old.b. Immunosuppression caused by medications or

HIV.c. On long term aspirin therapy.d. Chronic pulmonary, cardiac, hepatic, haemato-

logical, neurological, neuromuscular or metabolicdisorders.

e. Conditions such as cerebral palsy, intellectual anddevelopmental disability, seizure disorders etcwhich may impair respiratory function.

INTRODUCTION

During the 1918 Spanish Flu pandemic, oftendescribed as the most devastating epidemic in recordedhistory, 1 in 5 person was infected and an estimated 50 million lives were lost.1 The disease was sowidespread and pervasive that even children had a tunewhich they skipped rope to: “I had a little bird, its namewas Enza, I opened the window and In-Flu-Enza.”

EPIDEMIOLOGY

Past pandemics and the seasonal influenza havealways placed children, especially those less than twoyears old at increased risk of influenza related morbidityand mortality. Analysis of 7,706 confirmed cases of theNovel Influenza A (H1N1) from 28 countries in theEuropean Union up to 6 June 2009, showed that 54% ofthe cases occurred in children and young adults under 20 years of age (22% in children under 10 years).2

A report of 642 confirmed cases of Influenza A (H1N1)in the USA showed that 60% of cases were in thepaediatric population less than 18 years (20% in under10 year olds).3

This may suggest that the younger population aremore biologically susceptible to the virus than olderpersons. Their mobility and travel may also predisposethem to the virus. Some researchers have shown that 1 in3 persons aged above 60 years have pre-existing crossreactive antibodies, which may explain why only 4% and5% in the European and American Influenza A reportsrespectively, were in those more than 50 years old.

CLINICAL MANIFESTATIONS

Children are afflicted by many respiratory illnessesand it may be very difficult to distinguish more commonacute respiratory tract infections from the NovelInfluenza A infection. Besides, children are less likely topresent with the classical symptoms of Influenza A

Correspondence: Musa Mohd. Nordin,KPJ Damansara Specialist Hospital, 119, Jalan SS 20/10,Damansara Utama, 47400 Petaling Jaya, Selangor Darul Ehsan.

Musa Mohd. Nordin, FRCP, FAMM

The Novel Influenza A (H1N1) Infection in Infantsand Children

ANNOTATIONS

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42 Musa Mohd.

TRANSMISSION AND CASE FATALITY RATES

The Novel Influenza A (H1N1), which the WHOdeclared on June 11, 2009, as the causative strain of thefirst pandemic of the 21st century, bears a disturbingresemblance to the H1N1 virus strain which caused the1918 flu pandemic and is affecting more younger thanolder people.4 Transmissibilty of the Novel virus is alsomuch higher than the seasonal influenza, and theestimated rates of human-to-human transmission issimilar to the lower estimates of previous influenzapandemics. It has spread within a space of 6 weeks whatthe previous pandemics could only do in 6 months,facilitated by modern air travel.

Estimates of Case Fatality Rates (CFR) from theNovel Influenza A (H1N1) is lower than the seasonal flu(0.5-1%) which is lower than the Spanish Flu (2.5%)which is lower than the Avian Flu (50%). The EuropeanCentre for Disease Control & Prevention (ECDC) in itsrisk assessment report for H1N1 wrote; "a reasonableassumption is a hospitalization rate of 1-2% and CFR of0.1-0.2%".5 This was in comparison to earlier estimatesof 0.4% (4 in 1,000) based on data from Mexico.6 Thehigh estimates from Mexico was probably related to itbeing a new illness not early and correctly recognized;delay in seeking medical attention and the quality ofcritical care afforded to the patients who often presentedin a moribund condition. In the US alone, there are200,000 influenza related hospitalizations annually and36,000 influenza associated deaths during each influenzaseason. Though the disease severity and mortality rate ismuch less than the seasonal influenza, the virulence ofthe Novel Influenza A may change as it mutates and thepermissive transmission will further facilitate andpresent opportunities for the Novel virus to replicate andreassort itself in new host species; potentially evolvinginto a more lethal virus which would have a significantimpact on human history and the global economy.

CONTAINMENT AND MITIGATION PHASES

Global containment of the virus has failed and theWHO has stopped tallying laboratory confirmed cases asthe increase is very rapid and the available resourcescould be better utilized. The most effective strategy tobreak this exponential chain of transmission and controlthe epidemic is through a mass vaccination program. Thefirst pandemic vaccine trial in humans are underway inAustralia and if found to be safe and effective, a massimmunization program will be launched, earliest beforethe end of 2009.7

SPECIAL CONSIDERATIONS FOR CHILDREN

Meanwhile, during the mitigation phase, variousuniversal influenza pandemic preparedness programshave been implemented to decrease the global impact of

this Novel virus. Measures specific to the health andlives of children include:

a. Focusing on children’s hygiene is one of the bestway to reduce transmission of the flu virus. This isprobably because children are very sociable andenjoys the most amount of physical contact withother people. Encouraging parents, teachers andday care workers to promote frequent handwashing and other good hygiene practices wouldgo a long way towards mitigating this outbreak. InPittsburgh, during the Spanish Flu pandemic,school children were given information to takehome and warned not to gather in groups. A reviewof several published studies showed that frequenthand washing, using gloves, gowns and maskswith filtration, and isolating probable cases helpedto reduce transmission of viral respiratorydiseases.

b. Children with confirmed or probable Influenza Ainfection and not sick enough to warrant hospitalcare should be home quarantined and all relatedpublic health measures should be strictly adhered.

c. Hospitals and Health Care Workers (HCW) arebearing the brunt of this added clinical burden.Triage at the entry points of all healthcare facilitiesare meant to timely identify suspected cases forclinical management and decrease the risk oftransmission to other patients and HCW. Childrenshould not be brought to hospitals and otherhealthcare facilities unless they are sick andrequire specific treatment. Do not be intimidatedby HCW who are adorning masks, gowns andgloves because they are working in a high riskenvironment and require them for their personalprotection. During the onset of the first outbreak inMexico, in March-April 2009, 22 HCW developedinfluenza like illness (ILI) within 7 days of contactwith the index patient and required treatment withoseltamivir.8

d. A whole host of non-pharmacologicalinterventions were undertaken in 1918 to mitigatethe impact of the influenza pandemic.9 Theseincluded the wearing of surgical masks,encouraging people to stay home, prohibition ofpublic gatherings and the closure of schools. St.Louis in the US, which implemented an early andsustained strategy of school closures andcancellation of public gatherings did notexperience as severe an outbreak when comparedto other US cities. The WHO has recommendedthat the closure of schools is one of the mitigationmeasures that should be considered by countries ifthe pandemic continues to worsen.

e. Children are more likely to be sicker and die fromthe seasonal influenza than the Novel Influenza A.The seasonal influenza is preventable and allchildren should continue to get their annualseasonal flu shots. It is not expected to provide anysubstantial protection against the Novel Influenza

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The Novel Influenza A (H1N1) Infection in Infants and Children 43

A virus. The US CDC recently extended the use ofthe influenza vaccine to children up to 18 yearsfrom the previous 6 months – 5 year olds. Thoseabove 65 years and persons with co-morbiditieswere similarly listed as high priority for theinfluenza vaccination.

f. Parents should make sure that their children’sother immunizations are up to date. Many of thedeaths during the 1918 pandemic were not directlycaused by the H1N1 virus but were due tosecondary bacterial pneumonia which set in afterthe virus had weakened the body’s defences.10 Themost common bacteria isolated from ante-mortemand post-morten specimens were thepneumococcus (50%), haemophilus influenza(25%), staphylococcus aureus and meningococcus.The pneumococcal conjugate vaccine (PCV), the23-valent pneumococcal vaccine, the Hib vaccineand the quadrivalent meningococcal vaccine wouldhelp prevent against a big proportion of the killerco-pathogens.11

g. Because children are particularly susceptible tothe new flu virus, HCW may need to be especiallyalert to secondary bacterial infections in theirnarrower airways. The advent and availability ofeffective and affordable antibiotics against thesebacterial superinfections has helped to reducecomplications from influenza. If a child has hadthe flu for five to seven days and is not improvingor getting worse, this is one situation wheredoctors would need to seriously considerprescribing appropriate antibiotics.

h. The Novel Influenza A (H1N1) virus is susceptibleto the anti-virals, oral oseltamivir and inhaledzanamivir. They are most effective whencommenced within 48 hours of developing ILI andadministered for five days.12 Notwithstanding,many patients with Influenza A (H1N1) haverecovered spontaneously without anti-viraltreatment. The most common adverse effects ofoseltamivir are nausea and vomiting whichimproves by taking it with food. Children withsevere clinical illness, radiological abnormalitiesand other co-morbidities as outlined earlier shouldbe considered for early anti-viral therapy.

i. Sometimes antivirals are given to otherwise wellchildren who are known or strongly suspected tohave been exposed to another person with theNovel Influenza A virus. This chemoprophylaxiswith anti-virals is to prevent the child frombecoming infected with the virus or to make theinfection milder. Prophylactic oseltamivir isapproved for children 12 months or older andshould be started upon exposure and continued for7 to 10 days, at a lower dose than for therapy.Zanamivir is approved for chemoprophylaxis inchildren 5 years or older.

CONCLUSION

Since its first appearance in April 2009, at the US-Mexican border, the Novel Influenza A (H1N1) hasspread to over 160 countries, infected well in excess of200,000 people and claimed more than 800 lives.12 TheWHO on June 11, 2009, declared an influenza pandemiccaused by this Novel strain. Children and young adultsare more susceptible to the Novel strain than the elderlypopulation. Though the clinical syndrome is relativelyless severe than the seasonal flu, the human-humantransmission of the strain is universal and exponential.Global Influenza Pandemic Preparedness plans are inplace to mitigate the human and socio-economic impactof this Novel flu virus. No vaccine is presently availableto prevent infection with the Novel virus, break its chainof transmission and to contain and control the epidemic.Human trials with the pandemic vaccine are now inprogress and should be available for large scaleimmunization before the close of 2009.

REFERENCES

1. Johnson NPAS, Mueller J. Updating the accounts: globalmortality of the 1918-1919 Spanish Influenza pandemic. BullHist Med 2002; 76:105-115.

2. ECDC Surveillance Report. Analysis of influenza A (H1N1)individual case reports in EU and EEA countries. 10 July 2009.

3. Novel Swine-Origin Influenza A (H1N1) Virus Investigationteam. Emergence of a novel swine origin influenza A (H1N1)virus in humans. N Eng J Med 2009; 360:2605-15.

4. Taubenberger JK, Morens DM. 1918 Influenza: the mother of allpandemics. Emerg Infect Dis 2006; 12:15-22.

5. ECDC Interim Risk Assesment. Influenza A (H1N1) 2009Pandemic. 20 July 2009.

6. Fraser C. et al. Pandemic potential of a strain of influenza A(H1N1): early findings. Science 2009 May 14.

7. Isabel Leroux-Roels, Geert Leroux-Roels. Current status andprogress of prepandemic and pandemic influenza vaccinedevelopment. Expert Review of Vaccines, April 2009, Vol. 8,No.4: 401-423.

8. Rogelio Perez-Padilla et al. Pneumonia and respiratory failurefrom Swine-Origin Influenza A (H1N1) in Mexico. N Eng J Med2009; 361:680-689.

9. Markel H et al. Non-pharmaceutical interventions implementedby US cities during the 1918-1919 influenza pandemic. JAMA2007; 298(6): 644-654.

10. Hirsch E.F, McKinney M. Epidemic of bronchopneumonia atCamp Grant, Ill. Preliminary bacteriologic report. JAMA 1918;71:1735-6

11. Hall J.N, Stone M.C, Simpson J.C. The epidemic of pneumoniafollowing influenza at Camp Logan, Texas: Preliminary report.JAMA 1918; 71:1986-7

12. ECDC Interim Guidance. Public health use of influenza anti-virals during influenza pandemics. June 2009.

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44 KPJ Medical Journal 4:44–45 (2010)

The success of modern vaccines is one of the mostextraordinary accomplishments of medical science. Inearlier generations many children contractedcommunicable diseases like polio and whooping cough,frequently with devastating consequences. Somechildren died; others were left with permanentimpairments, perhaps dependent on a wheelchair. Butthe development of vaccines has made many of thesechildhood illnesses relatively rare and has thus improvedthe lifetime health and well-being of millions of kids.Children have quite clearly benefited more fromvaccines than from any other preventive public healthprogram (other than clean water and sanitation) inhistory.1

However, some parents have become complacentabout their children's immunisations. They havemistakenly presumed that these serious diseases havedisappeared or have been eradicated. Others have beenduped by the anti-vaccines lobby which thoughminiscule in numbers make up 80% of the"immunization websites" in cyberspace. We havebecome victims of our own success. Was it not GeorgeSantayana (1863-1952) who said, "Those who cannotremember the past are condemned to repeat it".2

A few parents have been frightened away by reportsof possible side effects associated with certain vaccinesand which have been blown out of proportion by the anti-vaccines groups. Evidence based vaccinology hasclearly demonstrated that the risks of not receivingimmunisations are immense. Today’s vaccines are safeand generally produce only mild side effects such asfever or localized redness. Severe adverse reactions areextremely rare.

For maximum effectiveness and protection,immunisations should be administered at particular ages.A child should receive most of his childhoodimmunisations before his second birthday which willprotect him against 10 major diseases (Fig. 1):

• 3 doses of Hepatitis B • 1 dose of Tuberculosis • 5 doses of DTP (Diphtheria,Tetanus, Pertussis) • 3-4 doses of Hib (Haemophilus influenza b)• 5 doses of Polio • 2 doses of MMR (Measles, Mumps & Rubella)

Immunisations are also available against a host ofother communicable diseases including chicken pox,rotavirus gastroenteritis, influenza, pneumococcal

infection, Hepatitis A and meningococcal meningitis.The optional vaccines are shown in Fig. 2.

The efficacy of vaccines in preventing life threateningdisease is undisputable, but most parents remainconcerned about subjecting their babies to many painfulinjections.

This has now been allayed by the availability of manycombination vaccines. Six of the ten Ministry of Healthvaccines are given in combination – DTP and MMRvaccines. A pentavalent vaccine (5 in 1 combo) and ahexavalent vaccine (6 in 1 combo) are now available.

These new combination vaccines will further decreasethe number of individual shots that children would need.For a change, less pain but more gains!

The combining of vaccines in a single injectionconfers various benefits to the child and family. It isundoubtedly less painful (since less injections) to thechild (and parents too!), more convenient to parents whoare less likely to forget vaccination dates thus ensuringbetter compliance. This further enhances the success ofthe country's vaccination program and the universalprotection of all of our children.

Teenagers do not get routine medical checkups andhence are not very good about getting the vaccines theyneed. Parents of adolescents should make an extra effort to rectify this blind spot in vaccination. Fig. 3summarises the recommended adolescent immunisationschedule.3

Adults including grandparents should similarlyreview their vaccination status to ensure optimal andlong term protection. Fig. 4 shows the recommendedadult immunisation schedule.4

This review attempts to summarise the choices thatare best for our children and adolescents. And as parentsand grandparents, we similarly need to update our ownvaccination status to enhance our protection againstvarious viruses and bacteria which are potentially lifethreatening or debilitating to our health.

Musa Mohd. Nordin, FRCP, FAMM1 and Zulkifli Ismail, FRCPCH, FAMM2

Vaccines – Protection for Life

1KPJ Damansara Specialist Hospital.

2KPJ Selangor Specialist Hospital.

Correspondence: Musa Mohd. Nordin,KPJ Damansara Specialist Hospital, 119, Jalan SS 20/10,Damansara Utama, 47400 Petaling Jaya, Selangor Darul Ehsan.

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Vaccines – Protection for Life 45

Vaccine 11-18 years old

Hepatitis B Catch up 3 doses

Diptheria, Tetanus, Pertussis dTap (adolescent preparation)

Measles, Mumps, Rubella Catch up 2 doses

Chicken Pox Catch up 2 doses

Meningococcal 1 dose

Influenza Annual dose

Hepatitis A Catch up 2 doses

Human Papillomavirus 3 doses

Fig. 3. Adolescent immunisation schedule

Fig. 1. Immunisation schedule

Fig. 2. Available vaccines

2-8 months 2-3 doses of Rotavirus vaccine

2-24 months 3 or 4 doses of Pneumococcal vaccine

After 12 months old Chickenpox vaccine

After 24 months old 2 doses of Hepatitis A

After 24 months old Meningococcal vaccine

After 6 months old Annual Influenza vaccine

After 9 years old 3 doses of Human Papillomavirusvaccine

REFERENCES

1. Paul A. Offit, Louis M. Bell. What every parent should knowabout vaccines. 1998, 4.

2. George Santayana. The Life of Reason. 1905.3. http://www.cdc.gov/vaccines/recs/schedules/child schedule.htm#

printable.4. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

NoScar

7 12 15(Thn 1) (Thn 6) (Ting 3)

Immunisasi primer Dos tambahan Sabah sahaja

KEMENTERIAN KESIHATAN MALAYSIA

Jadual Immunisasi Yang Disarankan Oleh Kementerian Kesihatan MalaysiaUmur (Bulan) Umur (Tahun)

Immunisasi0 1 2 3 4 5 6 12 18

BCG

Hep B

DTP

Hib

OPV

Measles

MMR

DT

T

Vaccine 19-49 years 50-64 years > 64 years

Tetanus, Diptheria,Tdap Tdap dT

Pertussis (dT or dTap)

Human PapillomavirusHPV - -

(HPV)

Measles, Mumps, Catch up Catch up Catch upRubella (MMR) 1 or 2 doses 1 dose 1 dose

Chicken Pox Catch up 2 doses

Influenza - 1 dose annually

Pneumococcal1-2 doses 1 dose

(polysaccharide)

Hepatitis A Catch up 2 doses

Hepatitis B Catch up 3 doses

Meningococcal 1 or more doses

Fig. 4. Adult immunisation schedule

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46 KPJ Medical Journal 4:46–47 (2010)

The Diagnosis Related Groups (DRGs) are a patientclassification scheme that was originally developed as ameans of relating the type of patients a hospital treats(i.e., its casemix or mixture of cases) to the costsincurred by hospitals.1 The initial motivation fordeveloping the DRGs was firstly to develop a languagethat is common for all the players in a hospital setup, andsecondly to relate the patients treated in a hospital withthe resources they require to be treated. Therefore, itcreates an effective framework for monitoring theutilization of services in a hospital setting.

Technically speaking the casemix group is a patientclassification that classifies patients into groups that arenot only clinically similar (clinical similarity) and requiressimilar amount of resources (resource homogeneity) tobe treated in a hospital.

Initially this patient classification system i.e. casemixsystem classifies only the patients that are admitted andtreated in the hospital facility due to some acuteproblems. So DRG classification is meant for acuteinpatient episodes only. But the later version of thecasemix grouping like International Refined DiagnosisRelated Group (IR DRG) can classify both inpatients aswell as patients treated in the ambulatory setup as well. Casemix groups, also known as Diagnosis relatedGroups (DRG) is a clinical classification, based on thediseases the patient is suffering from or the procedurethat the patient has undergone. These clinical conditionform the basis of the groups they are aggregated in,which are further refined on the basis of resourcehomogeneity.

This clinical information is then combined with otherpatient related information to assign the patient into aspecific DRG. The other patient related information

needed to assign DRG is age, gender, LOS, dischargestatus (what happen to patient when he goes out of thehospital) etc. Before the patient related clinicalinformation (diagnosis of the patient and the procedurehe has undergone) can be used to assign DRG, it shouldbe converted from free text diagnosis into codedinformation.

The process of converting the free text diagnosis andprocedures into codes is called clinical coding, and isbeing done by trained clinical coder in the medicalrecord department using international conventions. Theconvention adopted by the Ministry of Health Malaysiafor the disease coding is ICD 10, whereas for procedureit is ICD 9 CM.

The data requirement for the development of DRGbased casemix groups is shown in Fig. 1.

Zafar Ahmed, MBBS, MBA

Introduction to the Casemix Groups –Diagnosis Related Groups (DRGs)

Correspondence: Dr Zafar AhmedDirector/Clinical ServicesTotal Health Information Systems Sdn BhdNo. 39, Lorong Syed Putra Kiri,Off Jalan Syed Putra,50460 Kuala LumpurEmail: zafar@this.com.my

NO Data Variable

1 Patient Identifier

2 Patient Age in years

3 Patient Age in days (if less than one year)

4 Patient Gender

5 Patient Discharge disposition / status

6 Patient weight (if age is less than 7 days)

7 Patient Principal Diagnosis

8 Patient Secondary Diagnosis

9 Patient Principal Procedure

10 Patient Secondary Procedure

Fig. 1. Data required for DRG

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Introduction to the Casemix Groups – Diagnosis Related Groups (DRG) 47

All these data elements are available in the patientmedical record. Once these entire data element areextracted from the patient record, these are compiled in afix format in a ‘text’ (.txt) file, and run through thesoftware to assign DRG based on the logic of thecasemix system. The process is summarized (Fig. 2).

Once the DRG groups are created they can be used forcomplimenting many processes in the hospitalenvironment. For example:

• Management• Budgeting• Profiling• Benchmarking• Clinical research• Quality reporting• Global Use• Payment

ClinicalCoding

DemographicInformation

IR DRGGrouper

IR DRGGroups

(Age, Sex, LOS etc.)

ClinicalInformation

CaseNotes

FromHIS

Pat

ien

t

(Diagnosis / procedure)

Fig. 2. Work Flow – Case-Mix System

CONCLUSION

DRGs are one of the most important healthmanagement tool developed in the last century. It can beused both for clinical as well as managementenvironment with great ease and good results.

REFERENCE

1. Averill R.F, Muldoon J.H, Vertrees J.C et. The Evolution ofCasemix Measurement Using Diagnosis Related Groups (DRGs).

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48 KPJ Medical Journal 4:48–49 (2010)

Nurhayati Mokhty, MD, MMed

Radiological Quiz: A 20 Month Old Girl with Fever and Irritability

CLINICAL IMAGES

Correspondence: Dr Nurhayati MokhtyConsultant RadiologistKPJ Damansara Specialist Hospital

Fig. 1. Plain Radiography

Fig. 3. MRI Scan

Fig. 2. CT Scan

A 20 month old girl presented with fever, irritability and inability to walk. What is the diagnosis?

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Radiological Quiz: 20 month with Fever and Irritability 49

DISCUSSION

Findings:

1. Plain Radiography (Fig. 1)Disc space narrowing at L4/L5.

2. CT Scan (Fig. 2)Lucent lesion within the L5 vertebral body withcortical destruction and irregular margins.

3. MRI Scan (Fig. 3)T2 prolongation within the anterior right L5vertebral body, which extends to the L4-L5 discspace. There was no corresponding enhancementon the post contrast images. There is soft tissue inexpansion at the L5 level.

DIAGNOSIS

Osteomyelitis/discitis of lumbar spine.

Key points - osteomyelitis of vertebrae:

● In children the most common cause ofosteomyelitis is by hematogenous spread from aremote source.1

● Acute hematogenous osteomyelitis, despite itsname, may have a slow clinical development andinsidious onset.

● In general, osteomyelitis has a bimodal agedistribution. ❍ Acute hematogenous osteomyelitis occurs early

in life, usually in children. ❍ Conversely, direct trauma and contiguous focus

osteomyelitis are more common among adultsand adolescents than in children.2

● Symptoms in acute hematogenous osteomyelitisare insidious in onset and include: History of acutebacteremic episode, local edema, erythema andtenderness.

● The most common causes in the 4month to 4 yearage group are Staphylococcus aureus, group AStreptococcus species, Haemophilus influenzae,and Enterobacter species.

● The WBC count may be elevated, but it isfrequently normal. Other diagnostic clues areelevated ESR (usually elevated in 90%) andelevated C-reactive protein. Both are nonspecificfindings. However, C reactive protein may be moreuseful than the erythrocyte sedimentation rate,since it is elevated earlier than the erythrocytesedimentation rate (ESR).

● Plain film findings:❍ Acute osteomyelitis is first suggested by

overlying soft-tissue edema at 3-5 days afterinfection.

❍ Bony changes are not evident for 14-21 days andinitially manifest as periosteal elevationfollowed by cortical or medullary lucencies. By28 days, 90% of patients demonstrate someabnormality.

❍ Approximately 40-50% focal bone loss isnecessary to cause detectable lucency on plainfilms.

● CT Scan:❍ Soft tissue swelling.❍ Periosteal elevation.❍ Cortical destruction or medullary lucencies.

● MRI Scan:❍ The MRI is effective in the early detection. ❍ MRI findings in osteomyelitis are deceased

marrow signal on T1W images and iso to hyperintense signal intensity on T2W images.

❍ Sensitivity ranges from 90-100%.

REFERENCES

1. http://www.emedicine.com/emerg/topic349.htm. 2. Dahnert, Wolfgang. Radiology review manual, Fifth Edition.

Lippincott, Williams, and Wilkins. 2003: pg 217.

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