Parallel Session 2 – Towards Excellence through Evidence-based Practice I – Patient Care

The prevalence of diabetes mellitus (DM) is increasing all over the world. Diabetic foot ulcer (DFU) is one of the major recognized complications. A large prospective cohort study found that the annual incidence of ulceration for DM patients and amputation for DFU patients were 8.1 and 5.1%, respectively. The annual mortality of the patients with DFU were even higher compared with DM patients.(2) The pathophysiology of DFU is complex.(3) Because of its complexity and high prevalence, it constitutes a large medical and economic problem. Up to now, there is no superior proven practice in treating DFU. The recent evidence showed that negative pressure wound therapy (NPWT) is one of the common methods to treat DFU including Hong Kong. In our systematic review of the latest 10 years publications, the result showed that most of the evidence suggested NPWT was effective in treating DFU but the evidence was still unclear. Hence, there is a need to conduct a study to assess the efficacy of NPWT in the local settings. 


The objectives of this prospective observational study were: (1) to explore the effectiveness of NPWT; (2) to identify any risk factors in affecting DFU healing in using NPWT; (3) to make recommendations on the daily clinical practice. The study design is an open labeled 2-group design including conventional group (usual care) and NPWT group. This study conducted in 7 orthopaedic departments. The inclusion criteria were history of DM, age 18 or above, ulcer located at the foot, infection under control and the Saint Elain Wound Score System between 12-23. The exclusion criteria were high bleeding tendency, tumor patient, known auto-immune disease and un-cooperated patient. Each patient was followed 12 weeks.


Total 125 patients recruited, 62 in NPWT and 63 in control group. The basic demographics were comparable between groups. The results showed that the ulcers size, volume and severity were significantly higher in NPWT groups. The key findings showed that proportion of wound healing and healing rate was significantly higher in NPWT group than in conventional group. In the risk factor analysis, the regression model (adjusted R2=0.715) showed the larger wound size (below 50 cm2) and use of adjunctive methods afterwards were more beneficial for using NPWT in DFU healing. The adjunctive methods included skin graft, direct suture and other progressive wound closure method. This implies that larger wound size with the help of adjunctive method after NPWT application, the wound healing in DFU is enhanced.

Delayed cord clamping (DCC) enhanced placental transfusion which could increase immediate haemoglobin concentration in newborns and improved the iron stores of infants up to six months after birth. World Health Organization(2014) recommends DCC, with no earlier than 1 minute after birth, during the essential newborn care provision, for better maternal and infant outcomes on health and nutrition.


Objectives
- To promote evidence-based midwifery practice among 8HA birthing hospitals
- To reduce variation of practice on managing umbilical cord clamping after birth
- To promote and uphold baby’s health via DCC
- To develop specialty standard practice guideline 


Methods
- Review the current practice on managing umbilical cord clamping for newborn babies after birth among 8HA birthing hospitals
- Adopt the Johns Hopkins Nursing Evidence-based Practice (JHNEBP) model to enhance the DCC practice


Results
Among 8 HA birthing hospital, the overall DCC practice for the term vaginal birth babies was 76.7% in the year of 2022. There was an increase of 9.3% when compared with the data in 2019. 


Implications and opportunities
- Guideline on DCC among HA birthing hospitals developed to standardize practice
- Extend the practice to Caesarean Section birth and preterm babies (≥ 32 weeks of gestation)

Background
Post-operative hypothermia is a predisposing factor of surgical complications. Pre-operative warming for ≥ 10 minutes may reduce post-operative hypothermia. This CQI project aimed to identify the risks factors for post-operative hypothermia, evaluate the effectiveness of pre-operative warming and promote implementation of appropriate corporate practice in the perioperative nursing specialty.
Methodology
Eighteen operating theatres in 17 hospitals joined the project. Pre-operative warming was implemented in November 2019. Adult patients undergoing elective colorectal, urological and thoracic surgeries with general or spinal anaesthesia were warmed for ≥ 10 minutes pre-operatively. A control group consisting of similar patients in November 2018 was used.
Results
Nine hundred sixteen patients in November 2019 and 996 in November 2018 were recruited. It was subsequently found that 4 out of the 18 operating theatres had the same pre-operative warming protocol implemented in November 2018. Therefore, 373 patients from these 4 operating theatres were grouped into the implementation group. Univariate analysis revealed implementation of pre-operative warming, male gender, age ˃ 70, body mass index (BMI) ≤ 23 and blood loss > 300ml significantly associated with post-operative hypothermia. As there were substantial missing data in BMI and blood loss, they were not included in the subsequent multivariate analysis. Consequently, implementation of pre-operative warming, male gender and age > 70 were found to be independent factors that affected the incidence of post-operative hypothermia. A subgroup analysis of the patients operated in November 2019 showed pre-operative warming performance was also an independent factor that could reduce post-operative hypothermia. The benefit of pre-operative warming was most obvious in urology cases.
Conclusion
Male gender and age > 70 were risk factors for post-operative hypothermia. Implementation and performance of pre-operative warming reduced post-operative hypothermia. The benefit of pre-operative warming was most obvious in urology cases. The findings were subsequently used to formulate our first Specialty Nursing Practice Guideline in Maintenance of Perioperative Normothermia.

Dehydration among stroke patients has been cited in various research studies as it potentially affects the ischemic penumbra and influence stroke evolution in their acute phase of stroke. 
A team from Tuen Mun Hospital (TMH) Acute stroke unit (ASU) developed the fluid management bundle to ensure patients receive adequate hydration since July 2018 till present, aims to: 
- Evaluate the barriers encountered by staff in improving oral hydration
- Formulate and implement a simple and cost-effective interventions


A mixed methodology approach, in which three ‘Plan Do Study Act’ (PDSA) cycles were undertaken in October 2018, December 2019 and July 2021, adopted to achieve our aims. 
Amongst the 3 PDSA cycles, a new screening tool BUN/Creatinine ratio adopted besides the traditional Intake/Output chart followed by education and communication to nursing staffs as underpin the foundations of the workstream at the early stage. Program team then aware that be user-friendly, readily accessible and a consistent approach in real practice are the core principles for successful fluid management. 
Program then go through PDSA cycle 2 and 3, bundle workflow reviewed eventually. Educational leaflet of hydration and special water cup were dispatched to patients and bed head signage were designed and launched for alertness of ward staff. 
Outcome & Conclusion
Evaluation in each PSDA cycles noticed that a significant raised in the awareness of hydration needs from ward staffs with 93% of hydration plan in average were initiated by nurses. Throughout the new assessment tool, there were 69.6%, 73% and 64% of dehydrated patients being identified on admission, while in Day 4-7 reassessment, improvement of BUN/Creatinine ratio in dehydration risk patient was 8.7%, 15% and 13% respectively in the evaluation of the 3 PDSA cycles. 
A successful sustained fluid management program can only happen by ensuring a whole-team approach.