Parallel Session 1 - Towards Excellence through Evidence-based Practice

Nurse clinic service in Hong Kong was first developed in year 2000 in the Hospital Authority (HA). The nurse clinic was introduced at the time with the aims to improve patients’ access to care and clinical outcomes. In 2016, there was a review on the nurse clinics which later on were transformed into the integrated clinics. The integrated clinic model of Specialty Outpatient (SOP) Services was piloted in 2018, with inputs of a multidisciplinary team including doctors, nurses and allied health professionals. The HA specifically highlighted a key performance indicator in 2022for these multidisciplinary integrated clinics, which was the reduction of SOP waiting time. There is a shift of expectation of what nurse clinics can contribute over time, from individual patient to system outcomes. Pursuing this repositioning, one may ask, how can the nurse clinics do more and make bigger impacts? In this presentation, the following four questions will be raised and explored: (1) How to work smarter? (2) How to produce wider reach? (3) How to create bigger impacts? (4) How to build signature brand? Some key solutions in addressing these questions include population health management, technology, patient engagement and brand building. Population health management is recognized as an integrative, holistic and data-driven approach in managing a defined group of clients. Technology can enhance accurate and efficient assessment and treatment. With the accumulation of big data, AI models can be built to facilitate risk stratification and predictive analysis. Patient engagement is important to activate inner resources of individuals through informed decision-making and co-production of care planning in achieving best patient outcomes. A clear linkage of intervention with outcomes can help inform the signature piece of the nurse clinic, which embodies a distinctive and crucial component in an efficient and effective healthcare system.

Ever since 1974, Glasgow Coma Scale has provided a practical tool for bedside assessment of impairment of conscious level (Teasdale et al., 2014). While widely adopted in general and specialty units, variations in techniques in performing the assessment have emerged over time affecting reliability and communication (McLernon, 2014). In 2014, the details of the scale composition and its application were reviewed. A structured approach to assessment was set up which facilitated to deliver a basis for standardizing practice and to ensure the scale was useful and practical (Teasdale et al., 2014).


In this update, terms under three modes of behavior: eye opening, verbal response and motor response have been clearly described aimed at minimizing ambiguity. ‘Not testable’ term is added in each of the three modes of behavior. Denote ‘NT’ when there are patient factors such as swollen eyes, intubated or paralyzed which affect the rating of GCS (Teasdale et al., 2014). 


In Hong Kong Hospital Authority, most hospitals and specialties are still adhering to the previous version of GCS, introducing inconsistencies. Therefore, an evidence based practice approach is used to justify the advantages of new version of GCS. Literature review has been done to study the best practice to increase the reliability of GCS. Literatures advocated that reliability for the GCS components was higher than for the sum score (Reith et al., 2016). It is important to apply standardized approaches whenever a component is untestable. A non-numerical designation ‘NT’ should be assigned (Reith et al., 2016). In addition, factors like education / training, level of experiences, type of stimulus and conscious level of patient may affect the reliability of GCS (Reith et al., 2017).


For that reason, an e-learning material was developed to train HA staff on the updated version of GCS and related neurological assessment. The e-learning has been launched since December 2023 and an evaluation will analyze inter-rater reliability between nurses post-training. Standardizing applications can enhance GCS usefulness and consistency for improved patient outcomes.

Background


Transcutaneous carbon dioxide monitoring (TCM) offers a non-invasive and real-time assessment of patient's ventilation and oxygenation, making it a potential alternative to arterial blood gas analysis (ABG) for continuous monitoring of carbon dioxide. This pioneering clinical study represents the first investigation of its kind conducted in Hong Kong, contributing unique insights to the local context.


Objective


To compare TCM with ABG in the measurement of partial pressure of arterial carbon dioxide (PaCO2) in adult patients with respiratory problems.


Method


A non-interventional observational prospective cross-sectional clinical study was conducted in two medical wards of Ruttonjee Hospital from 8 May 2023 to 31 December 2023. TOSCA device was used to measure transcutaneous carbon dioxide (TcCO2) level, while arterial puncture for ABG was performed on the same occasion. Based on the literature review, the sensor temperature of the TOSCA device was set to 43°C to induce local vasodilation, enhance skin permeability to carbon dioxide, and improve gas diffusion at the pre-selected measurement site (i.e. second intercostal space in the mid-clavicular line). Bland-Altman analysis was used to evaluate the agreement between the measurement of TcCO2 from TCM and PaCO2 from ABG.


Results


A total of 59 paired measurements were analyzed, showing no significant difference between both pooled transcutaneous and arterial measurements (paired sample t-test). The mean bias ±SD between TcCO2 and PaCO2 was -0.75 ±4.01mmHg, with 95% limits of agreement ranging from -8.62 to 7.11 mmHg. In total, 5.08% of the measured values fell outside the acceptable clinical range of agreement (±7.5mmHg). A strong correlation (r=0.9, p< 0.001) between TcCO2 and PaCO2 was observed. During the study, there were no complications, like pain-related discomfort, formation of hematoma and nerve damage to blood vessels, observed on patients.


Conclusion


For adult patients with respiratory problems, TCM provides an accurate estimate of PaCO2. It offers a clinically acceptable, safe and reliable non-invasive alternative to ABG for painless, real-time, continuous monitoring of carbon dioxide levels without the need for invasive procedures or repeated ABG sampling.