By Jensen Ng, MBBS, MMed
Tan Tock Seng Hospital (TTSH) was founded in 1844 and is the second largest hospital in Singapore with a capacity exceeding 1,500 beds. It is strategically located in Central Singapore, at the intersection of two major highways.
The Neuroscience ICU (NICU) of TTSH has been in operation since the official opening of the current hospital premises in 2000. Since then, it has expanded to its current capacity of 14 Level 3 beds and four Level 2 Beds. The NICU functions as a single unit under the leadership of the NICU Director Dr. Wong Yu Lin from anaesthesiology, intensive care and pain medicine, with co-directors from neurosurgery and neurology, Dr. Ng Yew Poh and Dr. Oh Chia-Theng Daniel.
NICU patients admitted under the neurosurgery service are jointly managed by specialists from the departments of neurosurgery and anaesthesiology, while the specialists from neurology manage the patients admitted under the neurology service. All NICU patients receive multidisciplinary care from allied health professionals such as respiratory therapists, pharmacists, physiotherapists, speech therapists, occupational therapists and dieticians. A neurosurgery grand round takes place weekly. Twice a week, a multidisciplinary round comprising infectious disease specialists, microbiologists, pharmacists and intensivists discuss cases involving complex infections.
In 2017, the NICU admitted 1,824 patients, which represented a 2.8 percent increase from the year before. Of these, 789 were Level 3 patients. Seventy percent of the Level 3 patients were neurosurgical cases. As a tertiary center, it also frequently receives transfers from peripheral and foreign hospitals. In 2017, it accepted 35 such transfers.
The NICU of TTSH supports the clinical needs of the National Neuroscience Institute (NNI), caring for many of the patients before and after their major surgical and interventional radiology procedures. The NNI is the largest tertiary neuroscience center in Singapore and is renowned both locally and in the region for its clinical and research excellence. The highly specialized clinical staff of the NNI include 15 neurosurgeons and five interventional neuroradiologists.
In 2017, 58 mechanical thrombectomies were performed. Fifty coilings for intracerebral aneurysms were carried out, of which 70 percent were done on an emergent basis. A total of 1,195 neurosurgeries were performed in 2017, of which 654 were emergency surgeries. The top three surgeries were extraventricular drain insertion (151), decompressive craniectomy (128) and burrhole drainage (76). Fifty-nine aneurysm clippings and 59 excisions of intracerebral tumors were carried out. These figures attest to the volume and complexity of cases seen at NNI and TTSH NICU.
Quality Improvement (QI) Initiatives in NICU
The NICU in TTSH has been active in pursing quality improvement projects for the betterment of our patients. QI initiatives such as improving enteral nutrition delivery in intubated NICU patients, enhancing palliative care for NICU patients, urgent reversal of warfarin coagulopathy in NICU patients with intracranial hemorrhages (conjoint project with emergency medicine department), reducing oro-facial pressure ulcers due to endotracheal tube in intubated NICU patients and reducing catheter-associated urinary Tract infections are some examples of the continuous endeavors to improve patient-centric outcomes, and are part of the larger hospitalwide effort on organizational excellence. Many of these projects were initiated by our nursing colleagues.
The clinical staff of the NICU is actively engaged in the region to promote the development of neurocritical care, conducting regular training courses in neighboring countries (ASEAN countries such as Indonesia and Cambodia). In addition, the NICU regularly hosts observers from these countries on short attachments in order to share our experiences in our high-acuity, high-volume center. Besides core medical and nursing knowledge and skills of neurocritical care, important aspects in soft skills such as communication with family and relatives, breaking bad news, resident teaching, ICU management and leadership are shared with the observers. These initiatives are sponsored by Singapore-based nonprofit philanthropic organizations (such as Temasek Foundation International and Lee Foundation) that fund and support programs that aim to build capabilities in communities in Asia. Designed and implemented with TTSH as the program partner, these collaborations advance neurocritical care in the region.
The NICU is heavily involved in training and education, receiving anaesthesiology and critical care specialist trainees from hospitals across the country. These trainees undergo structured teaching programs and also benefit greatly from the high volume and varied case mix.
This year, trainers from the NICU conducted the inaugural Emergency Neurological Life Support (ENLS) course in the country. The response was overwhelming, reflecting an unmet need for a comprehensive training workshop addressing basic neurocritical care. It involved 31 participants from various backgrounds and levels of training. Several international faculty including Dr. Gene Sung, past president of the Neurocritical Care Society, were on hand to share their vast experience with the participants.
To complement the ENLS program, the course incorporated other elements central to neurocritical care, namely neuromonitoring, EVD management, neurological determination of death and neuroradiology. It also included a NeuroSimulation Workshop, where the participants had the opportunity to put what they learnt into practice in a realistic but safe environment.
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