INTRODUCTIONUltrasonographic evaluation of patients in cardiac arrest is currently not protocolised in the advanced cardiac life support (ACLS) algorithm. Potentially reversible causes may be identified using bedside ultrasonography that is ubiquitous in most emergency departments (EDs). This study aimed to evaluate the incidence of sonographically detectable reversible causes of cardiac arrest by incorporating an ultrasonography protocol into the ACLS algorithm. Secondary objectives include rates of survival to hospital admission, hospital discharge, and 30-day mortality.

MATERIALS AND METHODSWe conducted a prospective study using bedside ultrasonography to evaluate for potentially reversible causes in patients with cardiac arrest at the ED of National University Hospital, Singapore, regardless of the initial electrocardiogram rhythm. A standardised ultrasonography protocol was performed during the 10-second pulse check window.

RESULTSBetween June 2015 and April 2016, 104 patients were recruited, corresponding to 65% of all out-of-hospital cardiac arrest patients conveyed to the ED. Median age was 71 years (interquartile range, 55 to 80) and 71 (68.3%) patients were male. The most common rhythm on arrival was asystole (45.2%). Four (3.8%) patients had ultrasonographic findings suggestive of massive pulmonary embolism while 1 received intravenous thrombolysis and survived until discharge. Pericardial effusion without tamponade was detected in 4 (3.8%) patients and 6 (5.8%) patients had intra-abdominal free fluid. Twenty (19.2%) patients survived until admission, 2 of whom (1.9%) survived to discharge and beyond 30 days.

CONCLUSIONBedside ultrasonography can be safely incorporated into the ACLS protocol. Detection of any reversible causes may alter management and improve survival in selected patients.

Emergency Service, Hospital ; Humans ; Retrospective Studies ; Singapore

INTRODUCTIONAge-related physiological changes predispose older road users to higher mortality from traffic crashes. We aimed to describe the injury epidemiology of these patients, and explore the association between the comorbidity polypharmacy score (CPS) and outcomes.

MATERIALS AND METHODSThis retrospective study utilised data from the Trauma Registry in the National University Hospital, Singapore, between January 2011 and December 2014. Patients involved in traffic crashes aged 45 years and above with injury severity scores (ISS) of 9 and higher were included.

RESULTSThere were 432 patients; median age was 58 (interquartile range, 51 to 65.5) years with predominance of male patients (82.2%) and Chinese ethnicity (66%). Overall mortality was 9.95%, with lower odds associated with higher Glasgow Coma Scale (odds ratio [OR] 0.73; 95% confidence interval [CI], 0.65 to 0.81,<0.001), higher diastolic blood pressure (OR 0.98; 95% CI, 0.97 to 1.00,= 0.031), and lower ISS of 9 to 15 (OR 0.10; 95% CI, 0.02 to 0.43,= 0.002). The need for blood products was associated with higher mortality (OR 7.62; 95% CI, 2.67 to 21.7,<0.001). CPS did not predict mortality. Independent predictors of discharge venue included length of stay, tier of injury and CPS group. Moderate CPS was statistically significant for nursing home placement (OR 10.7; 95% CI, 2.33 to 49.6,= 0.002) but not for rehabilitation facility.

CONCLUSIONCPS score is useful in predicting discharge to a nursing home facility for older patients with traffic crashes. Further larger studies involving other trauma types in the Asian population are needed to evaluate its utility.

Accidents, Traffic ; statistics & numerical data ; Adolescent ; Age Distribution ; Bicycling ; injuries ; Child ; Child, Preschool ; Cohort Studies ; Emergency Service, Hospital ; statistics & numerical data ; Female ; Follow-Up Studies ; Fracture Fixation ; methods ; statistics & numerical data ; Fractures, Bone ; diagnosis ; epidemiology ; surgery ; Humans ; Injury Severity Score ; Male ; Prevalence ; Radiography ; methods ; Registries ; Retrospective Studies ; Risk Assessment ; Sex Distribution ; Singapore ; epidemiology ; Tomography, X-Ray Computed ; methods ; Trauma Centers ; Treatment Outcome ; Wounds and Injuries ; diagnostic imaging ; epidemiology ; therapy

INTRODUCTION: Flexible bronchoscopic intubation (FBI) is an important technique in managing an anticipated difficult airway, yet it is rarely performed and has a steep learning curve. We aim to evaluate if the integration of virtual reality gaming application into routine FBI training for emergency department doctors would be more effective than traditional teaching methods. METHODS: We conducted a randomised controlled trial to compare self-directed learning using the mobile application, Airway Ex* in the intervention group versus the control group without use of the mobile application. All participants underwent conventional didactic teaching and low-fidelity simulation with trainer's demonstration and hands-on practice on a manikin for FBI. Participants randomised to the intervention arm received an additional 30 minutes of self-directed learning using Airway Ex, preloaded on electronic devices while the control arm did not. The primary outcome was time taken to successful intubation. RESULTS: Forty-five physicians (20 junior and 25 senior physicians) were enrolled, with male predominance (57.8%, 26/45). There was no difference in time taken to successful intubation (median 48 seconds [interquartile range, IQR 41-69] versus 44 seconds [IQR 37-60], P=0.23) between the control and intervention groups, respectively. However, the intervention group received better ratings (median 4 [IQR 4-5]) for the quality of scope manipulation skills compared to control (median 4 [IQR 3-4], adjusted P=0.03). This difference remains significant among junior physicians in stratified analysis. CONCLUSION Incorporating virtual reality with traditional teaching methods allows learners to be trained on FBI safely without compromising patient care. Junior physicians appear to benefit more compared to senior physicians.

INTRODUCTION: Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation for preoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNC oxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO₂) during rapid sequence intubation (RSI) in ED patients compared to usual care. METHODS: This was a multicentre, open-label, randomised controlled trial in adult ED patients requiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at 60L/min) group or control (non-rebreather mask for preoxygenation and nasal prongs of at least 15L/min oxygen flow for apnoeic oxygenation) group. Primary outcome was lowest SpO₂ during the first intubation attempt. Secondary outcomes included incidence of SpO₂ falling below 90% and safe apnoea time. RESULTS: One hundred and ninety patients were included, with 97 in the intervention and 93 in the control group. Median lowest SpO₂ during the first intubation attempt was 100% in both groups. Incidence of SpO₂ falling below 90% was lower in the intervention group (15.5%) compared to the control group (22.6%) (adjusted relative risk=0.68, 95% confidence interval [CI] 0.37-1.25). Post hoc quantile regression analysis showed that the first quartile of lowest SpO₂ during the first intubation attempt was greater by 5.46% (95% CI 1.48-9.45%, P=0.007) in the intervention group. CONCLUSION Use of HFNC for preoxygenation and apnoeic oxygenation, when compared to usual care, did not improve lowest SpO₂ during the first intubation attempt but may prolong safe apnoea time.
Adult ; Cannula ; Emergency Service, Hospital ; Humans ; Intubation, Intratracheal ; Rapid Sequence Induction and Intubation ; Respiration, Artificial

INTRODUCTION: Inappropriate attendances (IAs) to emergency departments (ED) create an unnecessary strain on healthcare systems. With decreased ED attendance during the COVID-19 pandemic, this study postulates that there are less IAs compared to before the pandemic and identifies factors associated with IAs. METHODS: We performed a retrospective review of 29,267 patient presentations to a healthcare cluster in Singapore from 7 April 2020 to 1 June 2020, and 36,370 patients within a corresponding period in 2019. This time frame coincided with local COVID-19 lockdown measures. IAs were defined as patient presentations with no investigations required, with patients eventually discharged from the ED. IAs in the 2020 period during the pandemic were compared with 2019. Multivariable logistic regression was performed to identify factors associated with IAs. RESULTS: There was a decrease in daily IAs in 2020 compared to 2019 (9.91±3.06 versus 24.96±5.92, P<0.001). IAs were more likely with self-referrals (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.50-1.66) and walk-ins (aOR 4.96, 95% CI 4.59-5.36), and those diagnosed with non-specific headache (aOR 2.08, 95% CI 1.85-2.34), or non-specific low back pain (aOR 1.28, 95% CI 1.15-1.42). IAs were less likely in 2020 compared to 2019 (aOR 0.67, 95% CI 0.65-0.71) and older patients (aOR 0.79 each 10 years, 95% CI 0.78-0.80). CONCLUSION ED IAs decreased during COVID-19. The pandemic has provided a unique opportunity to examine factors associated with IAs.
COVID-19 ; Communicable Disease Control ; Emergency Service, Hospital ; Humans ; Pandemics ; Retrospective Studies ; SARS-CoV-2

INTRODUCTION: Pericardiocentesis is a potentially life-saving procedure. We compared two low-cost models-an agar-based model and a novel model, Centesys-in terms of ultrasound image quality and realism, effectiveness of the model, and learners' confidence and satisfaction after training. METHODS: In this pilot randomised 2x2 crossover trial stratified by physician seniority, participants were assigned to undergo pericardiocentesis training either with the agar-based or Centesys model first, followed by the other model. Participants were asked to rate their confidence in performing ultrasound-guided pericardiocentesis, clarity and realism of cardiac structures on ultrasound imaging, and satisfaction on a 7-point Likert scale before and after training with each model. RESULTS: Twenty participants with median postgraduate year of 4 (interquartile range [IQR] 3.75-6) years were recruited. Pre-training, participants rated themselves a median score of 2.5 (IQR 2-4) for level of confidence in performing pericardiocentesis, which improved to 5 (IQR 4-6) post-training with Centesys ( CONCLUSION Centesys achieved greater learner satisfaction as compared to the agar-based model, and was an effective tool for teaching ultrasound-guided pericardiocentesis and drain insertion.

INTRODUCTION: Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes. METHODS: We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge. RESULTS: A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again. CONCLUSION Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.
Aftercare ; Aged ; Female ; Hospitalization ; Humans ; Length of Stay ; Male ; Patient Discharge ; Retrospective Studies ; Singapore

INTRODUCTIONElderly patients with serious chronic diseases often present to the emergency department (ED) in the last moments of their life, many with identifiable trajectories of dying: organ failure, advanced cancer and chronic frailty. These patients and their families may benefit more from good end-of-life (EOL) care provision than the standard resuscitative approach. This study aimed to determine the incidence and nature of death among patients aged ≥ 65 years in an ED, and characterise their trajectories of dying.

METHODSThis was a retrospective study carried out over a one-year period in a tertiary ED. All ED deaths in patients aged ≥ 65 years over this period were included. Information on the patients' demographics, comorbidities and details of death were extracted from the hospital's electronic medical records database. Based on the available information, their Karnofsky Performance Status (KPS) scores and trajectories of dying were ascertained.

RESULTSIn one year, 197 patients aged ≥ 65 years died in the ED, 51.3% of whom suffered from serious chronic illnesses, with identifiable trajectories of dying. Of these patients, 46.5% had premorbid functional limitation with KPS scores of 0-40. However, only 14.9% of patients had a pre-existing resuscitation status and 74.3% received aggressive resuscitative measures.

CONCLUSIONThere is a significant burden of EOL care needs among elderly patients in the ED. Many of these patients have chronic illness trajectories of dying. This study underscores the need for improvement in EOL care provision for dying patients and their families in the ED.

Aged ; Aged, 80 and over ; Cause of Death ; Chronic Disease ; Comorbidity ; Death ; Electronic Health Records ; Emergency Service, Hospital ; Female ; Humans ; Karnofsky Performance Status ; Male ; Needs Assessment ; Retrospective Studies ; Singapore ; Terminal Care