Explore the vast range of titles available.

The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout. A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale). The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout. Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

BackgroundOlder patients’ attendances at EDs are rising. There are concerns that these individuals have prolonged stays, which have been shown to be associated with adverse clinical outcomes. We assessed the length of stay in older patients in a single ED in Singapore.MethodsThis was an observational retrospective study of ED attendances between 2017 and 2019 at the Singapore General Hospital (SGH) using the SGH ED database. The primary outcome was ED length of stay, with prolonged stay defined as 4 hours or more. The association between age (categorised into 18–44, 45–64, 65–84 and 85+) and length of stay was analysed using a mixed-effects logistic regression adjusting for variables like gender, ethnicity and triage acuity. Associations are expressed as adjusted ORs (AOR) with 95% CI. A subgroup analysis was performed for all considered variables.Results391 171 patients qualified for analysis; median age 57 years (IQR 37–70) and 51.5% male. The median length of stay increased across age categories (age 18–44, 3.53 hours; 45–64, 4.04 hours; 65–84, 4.32 hours; and 85+, 4.46 hours). Using patients aged 18–44 as a reference, the AORs for prolonged length of stay by age group were 45–64 AOR 1.17 (95% CI 1.13 to 1.21), 65–84 AOR 1.26 (95% CI 1.21 to 1.30) and 85+ AOR 1.25 (95% CI 1.18 to 1.31). In the subgroup analysis, there was no association between age and length of stay for patients admitted, having multiple comorbidities, having blood tests or having high acuity scores.ConclusionIn this Singaporean tertiary hospital, older patients had increased median stays and were more likely to stay in the ED for more than 4 hours. However, this did not apply in some subpopulations. This potentially suggests the need for systematic changes in discharge planning and triaging to reduce prolonged stays and their consequences for older patients.

BackgroundThe COVID-19 disease outbreak that first surfaced in Wuhan, China, in December 2019, has taken the world by storm and ravaged almost every country in the world. Emergency departments (ED) in hospitals are on the frontlines, serving an essential function in identifying these patients, isolating them early whilst providing urgent medical care. This outbreak has reinforced the role of Emergency Medicine in public health. This paper documents the challenges faced and measures taken by a tertiary hospital’s ED in Singapore, in response to the outbreak.Main bodyThe ED detected the first case of COVID-19 in Singapore on 22 January 2020 in a Chinese tourist and also the first case of locally transmitted COVID-19 on 3 February 2020. The patient journeys through the patient reception area in the ED and undergoes fever screening before being shunted to isolation areas within the ED. Management and disposition of suspect COVID-19 patients are guided by a close-knit collaboration between ED and department of infectious diseases. With increasing number of patients, back-up plans for expansion of space and staff augmentation have been enacted. Staff safety is also of utmost importance, with provision and guidelines for personal protective equipment and team segregation to ensure no cross-contamination across staff. These have been made possible with an early setup of an operational command and control structure within the ED, managing manpower, logistics, operations, communication and information management and liaison with other clinical departments.ConclusionWith the large numbers of undifferentiated patients managed by the ED to date, more than 820 patients with COVID-19 have been identified in the hospital. Not a single member of the staff of the SGH Emergency Department has come down with the illness. The various measures undertaken by the department have helped to ensure good staff morale and strict adherence to safety procedures. We share the lessons learnt so that others who manage EDs around the world can benefit from our experience.

There is a growing demand globally for emergency department (ED) services. An increase in ED visits has resulted in overcrowding and longer waiting times. The triage process plays a crucial role in assessing and stratifying patients' risks and ensuring that the critically ill promptly receive appropriate priority and emergency treatment. A substantial amount of research has been conducted on the use of machine learning tools to construct triage and risk prediction models; however, the black box nature of these models has limited their clinical application and interpretation. In this study, we plan to develop an innovative, dynamic, and interpretable System for Emergency Risk Triage (SERT) for risk stratification in the ED by leveraging large-scale electronic health records (EHRs) and machine learning. To achieve this objective, we will conduct a retrospective, single-center study based on a large, longitudinal data set obtained from the EHRs of the largest tertiary hospital in Singapore. Study outcomes include adverse events experienced by patients, such as the need for an intensive care unit and inpatient death. With preidentified candidate variables drawn from expert opinions and relevant literature, we will apply an interpretable machine learning-based AutoScore to develop 3 SERT scores. These 3 scores can be used at different times in the ED, that is, on arrival, during ED stay, and at admission. Furthermore, we will compare our novel SERT scores with established clinical scores and previously described black box machine learning models as baselines. Receiver operating characteristic analysis will be conducted on the testing cohorts for performance evaluation. The study is currently being conducted. The extracted data indicate approximately 1.8 million ED visits by over 810,000 unique patients. Modelling results are expected to be published in 2022. The SERT scoring system proposed in this study will be unique and innovative because of its dynamic nature and modelling transparency. If successfully validated, our proposed solution will establish a standard for data processing and modelling by taking advantage of large-scale EHRs and interpretable machine learning tools. DERR1-10.2196/34201.

Given the rapid turnaround of point-of-care testing, various studies have utilized RAD tests at the point of entry into the healthcare system.1–4 However, most of these studies have occurred during periods of heightened transmission, with detection rates of 5%–21%.1–4 RAD testing in clinical scenarios with lower incidence, such as asymptomatic individuals, may potentially result in low detection rates with high false-positive rates.5 False-positive RAD tests have resulted in SARS-CoV-2–negative patients being admitted to coronavirus disease 2019 (COVID-19) cohort wards, with subsequent nosocomial transmission.2 Conversely, given broad variations in potential infectivity among individuals with false-negative RAD tests,4 negative RAD tests need to be interpreted cautiously, especially in the context of significant contact history or clinical syndromes compatible with COVID-19. [...]40 patients tested positive for SARS-CoV-2 by RAD; among them, 29 tested positive by PCR, with a mean cycle-threshold value for SARS-CoV-2 E-gene of 18.9 (Fig. 1). [...]RAD testing for SARS-CoV-2 as part of an admission-triage strategy demonstrated high sensitivity and specificity, even in a low-incidence setting.

Intraosseous (IO) access is an important alternative to conventional intravenous access when intravenous access is difficult. A nonrandomized, prospective, observational study comparing flow rates with distal and proximal tibia IO access in adults using the EZ-IO–powered drill device. The proximal tibia was the first site of insertion, and a second IO was inserted in the distal tibia if clinically indicated. Intravenous saline infusion was started for all patients, initially without, then with a pressure bag device applied. From September 19, 2008 to November 3, 2010, 22 patients were recruited, with 20 proximal tibial and 22 distal tibia insertions. Two patients had only distal tibia IO insertions. Five distal tibia and 3 proximal tibia insertions had no flow when initiating normal saline infusion without pressure. Upon comparing the mean flow rates without pressure bag, it is significantly faster in the proximal tibia, 4.96 mL/min, compared with distal tibia, 2.07 ml/min, difference of 2.89 ml/min (95% CI 1.20-4.58). Flow rates with pressure bags also revealed a similar result. Flow rates in the proximal tibia were significantly faster, 7.70 ml/min to that of distal tibia, 3.80 ml/min, difference of 3.89 ml/min (95% CI 1.68-6.10). In both proximal and distal tibia groups, the flow rates are also significantly faster with pressure bags compared with without. Flow rates are significantly faster in the proximal tibia compared with the distal tibia. In addition, flow rates with pressure bags are significantly faster than without pressure bags in both groups.

Targeted temperature management post-cardiac arrest is currently implemented using various methods, broadly categorized as internal and external. This study aimed to evaluate survival-to-hospital discharge and neurological outcomes (Glasgow-Pittsburgh Score) of post-cardiac arrest patients undergoing internal cooling verses external cooling. A randomized controlled trial of post-resuscitation cardiac arrest patients was conducted from October 2008–September 2014. Patients were randomized to either internal or external cooling methods. Historical controls were selected matched by age and gender. Analysis using SPSS version 21.0 presented descriptive statistics and frequencies while univariate logistic regression was done using R 3.1.3. 23 patients were randomized to internal cooling and 22 patients to external cooling and 42 matched controls were selected. No significant difference was seen between internal and external cooling in terms of survival, neurological outcomes and complications. However in the internal cooling arm, there was lower risk of developing overcooling (p=0.01) and rebound hyperthermia (p=0.02). Compared to normothermia, internal cooling had higher survival (OR=3.36, 95% CI=(1.130, 10.412), and lower risk of developing cardiac arrhythmias (OR=0.18, 95% CI=(0.04, 0.63)). Subgroup analysis showed those with cardiac cause of arrest (OR=4.29, 95% CI=(1.26, 15.80)) and sustained ROSC (OR=5.50, 95% CI=(1.64, 20.39)) had better survival with internal cooling compared to normothermia. Cooling curves showed tighter temperature control for internal compared to external cooling. Internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival-to-hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia.

Launched in January 2022, the SingHealth Patient Advocacy Network at the Department of Emergency Medicine (SPAN@DEM) represents the first emergency department-specific advocacy group in Singapore. This initiative marks a significant advancement in local patient advocacy efforts because it employs a shared collaborative model to address the needs and concerns of patients within the unique context of the emergency department environment. SPAN@DEM emerged in recognition of the limitations of existing cluster-level advocacy groups, which are inadequate to address specific challenges inherent to the fast-paced, high-pressure nature of the emergency department. In this article, we describe the establishment of SPAN@DEM, discuss the challenges and considerations encountered, and reflect on lessons gleaned through this journey. A start-up committee, comprising two emergency physicians and four patient advocates, was convened to delineate the processes required to form a new patient advocacy group. Key features of SPAN@DEM include co-leadership by an emergency physician and a patient advocate, and diverse membership composition with equal representation from health care professionals and patient advocates. SPAN@DEM convenes quarterly with informal luncheons during meetings to foster open communication between advocates and health care staff. Membership is voluntary and motivated solely by altruism, and all members are required to participate in mandatory advocacy training to empower them to provide more actionable insights. Since its inception, SPAN@DEM has implemented several initiatives such as PIKACHU (Project to Improve next-of-Kin Advice, Communications and Helpful Updates)-a suite of quality improvement measures that resulted in improved patient and next-of-kin satisfaction rates and reduced formal communication-related complaints-and Digital FAQ-an online web-based resource designed to clarify emergency department processes for patients. SPAN@DEM advocates have also contributed to the planning, design, and transition to the new Emergency Medicine Building. More importantly, SPAN@DEM has fostered a cultural shift towards patient-centered care, with the department now routinely engaging patient advocates in decisions affecting patient and next-of-kin experience. SPAN@DEM exemplifies the value of specialized emergency department-specific advocacy groups in advancing patient-centered emergency care. This model may serve as an exemplar for other health care institutions seeking to enhance patient advocacy efforts.

Air pollution exposure may increase the demand for emergency healthcare services, particularly in South-East Asia, where the burden of air-pollution-related health impacts is high. This article aims to investigate the association between air quality and emergency hospital admissions in Singapore. Quasi-Poisson regression was applied with a distributed lag non-linear model (DLNM) to assess the short-term associations between air quality variations and all-cause, emergency admissions from a major hospital in Singapore, between 2009 and 2017. Higher concentrations of SO2, PM2.5, PM10, NO2, and CO were positively associated with an increased risk of (i) all-cause, (ii) cardiovascular-related, and (iii) respiratory-related emergency admissions over 7 days. O3 concentration increases were associated with a non-linear decrease in emergency admissions. Females experienced a higher risk of emergency admissions associated with PM2.5, PM10, and CO exposure, and a lower risk of admissions with NO2 exposure, compared to males. The older adults (≥65 years) experienced a higher risk of emergency admissions associated with SO2 and O3 exposure compared to the non-elderly group. We found significant positive associations between respiratory disease- and cardiovascular disease-related emergency hospital admissions and ambient SO2, PM2.5, PM10, NO2, and CO concentrations. Age and gender were identified as effect modifiers of all-cause admissions.

Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations. To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores. This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021. Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis. The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores. In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.