Safety Culture in Acupuncture Practice in a Tertiary Hospital: The Singapore General Hospital Experience

Introduction

Acupuncture is a complementary medical therapy that involves the insertion of sterile needles into selected points in the body to produce therapeutic effects. This is a relatively safe treatment method but also an invasive one. Appropriate patient safety measures and protection of both patients and practitioners need to be implemented during acupuncture treatment.^1–3 This article reports the authors' experience at Singapore General Hospital (SGH) and provides a set of guidelines that may help health care practitioners to perform safe acupuncture treatment.

Acupuncture has been practiced as a method of healing from the Zhou Dynasty (the Warring States Period) to the Qin-Han Dynasty (500–200 bc) in China. In November 1997, the National Institute of Health of China, endorsed acupuncture as a complementary treatment option for treating various medical conditions, and it is being increasingly accepted worldwide. Over the years, clinical trials have been conducted, providing increasing evidence of efficacy in several settings, including pain management; prevention and treatment of nausea and vomiting; treatment of addictions to alcohol, tobacco, and other drugs; treatment of pulmonary problems, such as asthma and bronchitis; and rehabilitation after neurological damage, such as stroke. ⁴

Acupuncture has been used in Singapore for more than 100 years. Major issues in using acupuncture as a complementary or alternative therapy include a lack of standardization and professional guidelines for acupuncture services. In 1995, the Ministry of Health in Singapore set up an Acupuncture Research Clinic and Committee to evaluate the efficacy and safety of acupuncture. ⁵ Following that, Acupuncture Units were set up in Singapore General Hospital (SGH) and at National University Hospital in 1998. After the establishment of the Traditional Chinese Medicine Practitioner Board (TCMPB) in 2001, Singapore and China had also signed an agreement to exchange knowledge of acupuncture from China with expertise in health care management from Singapore. Currently there are 200–300 TCM students graduating in Singapore every year. As of TCMPB's report of 2011, there was a total of 2679 Traditional Chinese Medicine (TCM) practitioners registered with the TCMPB Board, with 1198, in registered as both TCM physicians and acupuncturists. The data for 2012 were not issued as of this writing. Less than 1% of these practitioners were working in Western medical hospitals.

In 2010, according to the Singapore TCMPB's annual report, ⁶ 5 complaints against registered TCM practitioners were reported. With the support of statutory declarations or public officers, the TCMPB also looked into 5 complaints deferred from 2009 for decisions. Inquiry regarding 1 case was initiated in 2010 and was continued in 2011. A High Court appeal initiated by a TCM practitioner against the Board's decision in 2008 was concluded in 2010.

SGH is the biggest Western medical hospital in Singapore.The Acupuncture Unit (AU) was set up in 1998 under the purview of the hospital's the Department of Neurology. Based on data from 2008 to 2011 ∼69% of patients (Table 1) referred to this unit had pain conditions, including neck pain, lower back pain, and chronic headaches. Two thirds of the referrals were co-managed with physicians from the hospital's Pain Management Clinic, leading to the merging and establishment of the Pain Management Centre (PMC) in 2007. Other conditions managed include stroke, Bell's palsy, and insomnia.

The objective of the article is to describe the safety culture practice in the Acupuncture Services Clinic, in the PMC of SGH, with an emphasis on patients and staff education, infection control, consent taking, procedure documentation, discharge advice, and follow-up plans. The goals are to share these experiences with safety culture practiced in an acupuncture service at a tertiary hospital in Singapore with other acupuncturists and TCM practitioners, to assess the risks and help practitioners implement practical strategies for the safety and prevention of complications, and strengthen standardization and modernization of acupuncture, thus, ensuring professional delivery of care and treatment.

Methods

The occurrence of adverse events in acupuncture is extremely low, although life-threatening events can still occur (e.g., pneumothorax.)^2,3 With the use of disposable needles, the risk of transmission of bloodborne infections (hepatitis B, hepatitis C, and human immuodeficiency virus) is negligible. In line with the hospital's high safety standards—through various rigorous audits such as that of the Joint Commission International—a stringent safety culture and practice has been maintained. The following sections discuss particular aspects of this safety culture and practice.

Obtaining Consent, Procedure Documentation, and Proper Record Keeping

All patients are asked to make an appointment with a referral letter. Referral must be made by a registered doctor, indicating the patient's clinical diagnosis, relevant history, and current medications. Patients are required to book appointments to see the acupuncturist. Patients are also required to register at the counter upon arrival. Each patient's blood pressure (BP), heart rate (HR), and temperature are taken and recorded by the nurse prior to consultation with the acupuncturist. Then the acupuncturist will evaluate the patient, and formulate and discuss a treatment plan with the patient.

Informed consent is obtained prior to treatment, and patients are always fully informed about their treatment options, expected prognosis and, relative risks.^2,3,7,8 The acupuncturist will complete the Acupuncture Services Assessment Form, which includes patient information, such as name, address, main complaint, related medical history and previous treatments, current physical examination findings, aggravating and relieving factors, TCM diagnosis, current acupuncture treatment, and treatment plan. The form is then included into the patient's medical record and kept for 3 years.

A course of acupuncture treatments generally involves 5 sessions, with an average of 1–2 sessions per week and 30 minutes for each session. For acute cases, acupuncture treatment may be given more than 2 times per week. During the acupuncture treatment, most patients will receive needling, some will receive electroacupuncture (EA), cupping, and/or heat treatment in addition to needling. During and after treatment, patients are monitored closely by the acupuncture assistant or nurse, who informs the acupuncturist if the patient is experiencing any discomfort. Needles are removed while pressing the areas that were needled gently with sterile cotton balls when treatment is finished. The number of the needles removed is checked to ensure that this number corresponds with the number of the needles inserted. Table 2 shows Acupuncture Workflow and Policy. Upon completion of a course, a patient will be then reviewed to assess the outcome and discuss any further treatment plans. Figure 1 shows the Acupuncture Services Process Map.

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FIG. 1.

Acupuncture service process map.

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Table 2.

Acupuncture Workflow and Policy

Acupuncture procedure items	Requirements
Write acupuncture referral letter	By registered doctor in Singapore
Make an appointment	By phone or in person
Register at counter and complete information sheet	Before consultation
Obtain consent	Ensure that patient understands acupuncture treatment and the risks involved
Collect medical history, investigate, diagnose, and explain the treatment plan to patient	Record into the case sheet by acupuncturist
Assist patient into the correct position, and expose the area for treatment; provide sheets and gowns if necessary	In the treatment room with an assistant present, ensures privacy and dignity while allowing access to the treatment area
Disinfect needling area and acupuncturist's hands; disposable gloves to be used at all times	Follow strictly the infection control policy of SGH, reducing the risk of cross-infection and exposure of staff to blood or body fluids
Correct needles, acupoint, and equipment to be used; always check the number of needles used on patients	Ensure maximum treatment efficacy and avoid needles being left in situ

SGH, Singapore General Hospital.

Results

Over the past 14 years, 68,504 acupuncture treatment sessions have been carried out in the Acupuncture Services Clinic in PMC. Table 1 shows the results of acupuncture patients from 1998–2011 in SGH. From 2008 to 2011, 2195 patients received acupuncture, Among these patients, 82% were Chinese, 9% were Indian, 4% were Malay, and 5% were others; and 61.5% were females; 97.1% were outpatients; and 2.1% were in-patients. The reasons for referrals included: pain relief (69%), numbness and weakness (post–acute-stroke rehabilitation; chronic spasticity with weakness (16%); and others (14%). For patients referred for pain management, the average pain durations were: >10 years (6%); 5–9 years (15%); 2–5 years (30%); 1 month–1year (37%); and within 1 month (12%). Payment modes were: covered by government (31%); covered by employers (17%); payment covered by insurance (1.2%); and self-payment (51%).

There was a significant trend of an increasing number of patients visiting the Acupuncture Services over time (1998–2002: 1822 patients; 2003–2007: 2685 patients; and 2008–2011: 2195 patients; Table 3). The total number of treatment sessions over the years has also had increasing trend (1998–2002: 18,497 treatment sessions; 2003–2007: 26,621 sessions; and 2008–2011: 23,386 sessions). The daily number of patient cases was also increasing over the years (1998–2002: 10 cases/day; 2003–2007: >20 cases/day; and 2008–2011: >25 cases/day). Although there was an increasing trend of patient load over time, safety was not compromised,as indicted by the data for infection cases, broken-needle cases, adverse events, and needle-injury cases. The occurrence of these adverse events has always been maintained at zero, which has highlighted the safety culture and practice in the PMC.

In addition to providing clinical services, some acupuncture-related research articles were published in peer-reviewed scientific journals from 2003 to 2010.^8–11 Another four research projects are still ongoing, including one project that involves evaluating the effect of acupuncture therapy for improving semen parameters and sperm's fertilizing ability. The preliminary study results have shown a significant linear increase of sperm's fertilizing ability (p<0.001) after treatment (data not shown).

Discussion

Acupuncture is part of TCM and has been an age-old traditional therapeutic method practiced in Singapore. It faces the same problems as TCM, including lack of practice standardization and guidelines.^1–4 With the support from the Singapore Ministry of Health, an Acupuncture Research Clinic and Committee was set up in 1995; thus, the efficacy and safety of acupuncture were then evaluated properly in Singapore. In 1998, Acupuncture Units were set up in two Western medical hospitals in Singapore: Singapore General Hospital (SGH) and National University Hospital.

Over the years, being in a Western medical hospital environment, the Acupuncture Services Clinic in SGH has implemented a stringent safety culture and practice, and the practice was continually refined through various rigorous audits such as that conducted by the Joint Commission International. Good treatment outcomes were achieved with respect to adverse events and infection rates kept at very low levels.

In Singapore, there are <1% of the 2540 TCMPB-registered TCM practitioners working in Western medical hospitals. The safety culture and practice standard of TCM clinics varies and did not meet expect standardization criteria. ⁶ It is therefore important to share the SGH experiences in safety culture and practice with other acupuncturists and TCM practitioners inside and outside Singapore, to emphasize on the importance of assessing safety risks, implementing practical safety strategies, preventing complications, strengthening standardization, modernizing acupuncture, and ensuring professional delivery of care.

The aspects that the SGH safety culture and practice particularly emphasizes are patient and staff education; infection control; standardization of procedures, protocols and services delivered by trained accredited TCM practitioners; obtaining consent and procedure documentation^2,7; discharge and follow-up plans; and, finally, systems upgrades and equipment safety maintenance.

Patient education keeps patients well-informed about their conditions and treatments, therefore minimizing possible doubts and queries from patients, allowing acupuncturists to conduct treatment and manage patient confidently. Staff continuing education enables the SGH staff to maintain high professional standards and up-to-date knowledge in terms of not only clinical skills and knowledge, but also service quality and safety. This practice raises and maintains a high level of professionalism among all members of the SGH staff.

Implementing and following strictly the SGH Infection Control protocol plays a major role in reducing infection risks and incidents. This is complemented further by the implementation of standardization of procedures, protocols, and services provided. Standardized protocols ensure that patient treatments are maintained with safety and efficacy. This then translates to safer and better patient experiences as well (see Table 2). SGH acupuncturists are assessed yearly with a Competency-Based Assessment, which encourages them to maintain high levels of competency in their practices consistently.

Detailed documentation of procedures and implementation of discharge and follow-up plans require concise recording of patients' case notes. It is important for treatment efficacy during each follow-up session and also maintains treatment safety by preventing safety-related incidents, such as wrong-site treatment. Such documentation is also important when patients are treated by different acupuncturists for different follow-up sessions; this documentation maintains a high-level of treatment follow-up continuity.

Via consistent systems upgrade, such as electronic patients' appointment and reminder systems, the SGH hospital system facilitates the entire process of treatment and increases patient care efficiency. Equipment is constantly monitored and maintained by regulatory bodies such as the Health Science Authority and the Department of Biomedical Equipment of SGH. These measures ensure that safety is not compromised during treatment.

Utilizing a multipronged approach involving the abovementioned aspects, the SGH Acupuncture Clinic has managed to inculcate and maintain a high standard of safety culture and practice that has become second nature to the staff especially during treatment procedures. The most obvious result was seen in the increasing number of patients and treatment sessions over the past 14 years that SGH had, yet maintaining a zero-incident rate in the Acupuncture Services Clinic, as mentioned in the Results section. This trend of increasing patient and treatment load in our clinic corresponds to the SGH implementation of its safety culture and practice. This possibly suggests that that the SGH approach of safety culture and practice in the acupuncture clinic helps to: (1) facilitate efficient clinical work flow while always maintaining high levels of safety; (2) lead to higher levels of treatment efficacy and efficiency; and, (3) finally, result in increasing patient loads. This also possibly suggests that implementing a good safety culture and practice instills in patients a higher level of trust and confidence in not only the practitioners but the treatments as well, leading to higher levels of patient compliance, therefore, also possibly producing higher treatment efficacy and efficiency.

It is very common for practitioners to find it particularly hard to allocate time for research in their often crowded clinical work schedules. Therefore, maintaining a high standard in safety culture and practice resulting in higher efficiency in the SGH clinical work flow enables the acupuncturists to find time to partake in academic research in addition to their clinical work. Participating in research is key, because it allows the acupuncturists to continually bring new knowledge from the bench to the bedside and vice versa. This also allows them to be continually updated with the latest improvements and updates in the field of acupuncture and medicine which are always ever-changing.

As seen, by implementing a robust safety practice and culture with the emphasis on continuing education, staff professional development, teamwork, and clinical competency has resulted in higher work efficiency and treatment efficacy. In addition, the SGH Acupuncture Services Clinic has evolved, raised, and modernized the professional standards in acupuncture practice more, compared to what has occurred in average TCM and acupuncture clinics in Singapore.

The authors of this report hopes that sharing the successful SGH experience with other TCM practitioners and acupuncturists will be useful. In addition, there are practical solutions and suggestions further improvement:

(1) Implementation of continuing education for staff members

Conclusions

In the past decade, acupuncture has seen substantial development in several aspects: TCM doctors are adopting a more-scientific approach in their practices; Western doctors and researchers are recognizing that acupuncture can offer an alternative treatment for difficult cases; and patient safety is becoming of paramount importance in acupuncture and TCM.

Acupuncture treatment has been modernized in SGH over the years. With the robust safety practice and culture, plus the emphasis on continuing education and staff professional development, SGH has been able to nurture good teamwork, provide competent service, keep adverse events and infection rates at very low levels, and obtain good treatment outcomes. The authors hope that sharing this information could provide other practitioners and institutions ideas so that some aspects of the practice can be incorporated into their routine work in a more standardized and evidence-based manner, while maintaining the fundamental tenets of this ancient therapy.