The growth of emergency services in Singapore over years in terms of volume and complexity is relentless. In the pre-hospital environment, ambulance call volumes have more than doubled from 62,095 in 1997 to 142,549 cases in 2012. The use of emergency ambulances services should be commensurate with the timeframe of which the medical condition is deteriorating or the potential for sudden catastrophic outcomes. Activation of the EAS ambulance for STEMIs and strokes help to reduce the D2B time and time to thrombolysis. Patients at risk of AMI or stroke often fail to recognise the symptoms and hence fail to activate the EMS system. Physicians do have a role to identify those at risk to educate them to achieve better outcomes. Good documentation of positive and significant negative findings and relevant tests provides a baseline to expedite patient assessment at the ED. An understanding of the available ED resources as well as the access to services, especially when subspecialty consultation is needed, helps to improve the appropriateness of referrals.

The growth of emergency services in Singapore over years in terms of volume and complexity is relentless. In the pre-hospital environment, ambulance call volumes have more than doubled from 62,095 in 1997 to 142,549 cases in 2012. The use of emergency ambulances services should be commensurate with the timeframe of which the medical condition is deteriorating or the potential for sudden catastrophic outcomes. Activation of the EAS ambulance for STEMIs and strokes help to reduce the D2B time and time to thrombolysis. Patients at risk of AMI or stroke often fail to recognise the symptoms and hence fail to activate the EMS system. Physicians do have a role to identify those at risk to educate them to achieve better outcomes. Good documentation of positive and significant negative findings and relevant tests provides a baseline to expedite patient assessment at the ED. An understanding of the available ED resources as well as the access to services, especially when subspecialty consultation is needed, helps to improve the appropriateness of referrals.

INTRODUCTION: Bystander cardiopulmonary resuscitation (B-CPR) is associated with improved out-of hospital cardiac arrest survival. Community-level interventions including dispatcher-assisted CPR (DA-CPR) and myResponder were implemented to increase B-CPR. We sought to assess whether these interventions increased B-CPR. METHODS: The Singapore out-of-hospital cardiac arrest registry captured cases that occurred between 2010 and 2017. Outcomes occurring in 3 time periods (Baseline, DA-CPR, and DA-CPR plus myResponder) were compared. Segmented regression of time-series data was conducted to investigate our intervention impact on the temporal changes in B-CPR. RESULTS: A total of 13,829 out-of-hospital cardiac arrest cases were included from April 2010 to December 2017. Higher B-CPR rates (24.8% versus 50.8% vs 64.4%) were observed across the 3 time periods. B-CPR rates showed an increasing but plateauing trend. DA-CPR implementation was significantly associated with an increased B-CPR (level odds ratio [OR] 2.26, 95% confidence interval [CI] 1.79-2.88; trend OR 1.03, 95% CI 1.01-1.04), while no positive change was detected with myResponder (level OR 0.95, 95% CI 0.82-1.11; trend OR 0.99, 95% CI 0.98-1.00). CONCLUSION B-CPR rates in Singapore have been increasing alongside the implementation of community-level interventions such as DA-CPR and myResponder. DA-CPR was associated with improved odds of receiving B-CPR over time while the impact of myResponder was less clear.

INTRODUCTIONThere is interest in surveillance systems for outbreak detection at stages where clinical presentation would still be undifferentiated. Such systems focus on detecting clusters of syndromes in excess of baseline levels, which may indicate an outbreak. We model the detection limits of a potential system based on primary care consults for the detection of an outbreak of severe acute respiratory syndrome (SARS).

MATERIALS AND METHODSData from an averaged-sized medical centre were extracted from the Patient Care Enhancement System (PACES) [the electronic medical records system serving the Singapore Armed Forces (SAF)]. Thresholds were set to 3 or more cases presenting with particular syndromes and a temperature reading of >or=38oC (T >or=38). Monte Carlo simulation was used to insert simulated SARS outbreaks of various sizes onto the background incidence of febrile cases, accounting for distribution of SARS incubation period, delay from onset to first consult, and likelihood of presenting with T >or=38 to the SAF medical centre.

RESULTSValid temperature data was available for 2,012 out of 2,305 eligible syndromic consults (87.2%). T >or=38 was observed in 166 consults (8.3%). Simulated outbreaks would peak 7 days after exposure, but, on average, signals at their peak would consist of 10.9% of entire outbreak size. Under baseline assumptions, the system has a higher than 90% chance of detecting an outbreak only with 20 or more cases.

CONCLUSIONSSurveillance based on clusters of cases with T >or=38 helps reduce background noise in primary care data, but the major limitation of such systems is that they are still only able to confidently detect large outbreaks.

Adult ; Body Temperature ; Cluster Analysis ; Communicable Diseases, Emerging ; epidemiology ; Computer Simulation ; Fever ; diagnosis ; Hospitals, Military ; utilization ; Humans ; Medical Records Systems, Computerized ; Middle Aged ; Military Medicine ; Military Personnel ; statistics & numerical data ; Monte Carlo Method ; Personnel, Hospital ; statistics & numerical data ; Primary Health Care ; statistics & numerical data ; Referral and Consultation ; statistics & numerical data ; Sentinel Surveillance ; Severe Acute Respiratory Syndrome ; diagnosis ; epidemiology ; Singapore ; epidemiology

INTRODUCTIONThis study was a descriptive analysis of national ambulance case records and aimed to make practical safety recommendations in order to reduce the incidence of drowning in swimming pools.

METHODSA search was performed of a national database of descriptive summaries by first-responder paramedics of all 995 calls made to the Singapore Civil Defence Force between 1 January 2012 and 31 December 2014. We included all cases of submersion in both public and private pools for which emergency medical services were activated.

RESULTSThe highest proportion of drowning cases occurred in the age group of 0-9 years. Males accounted for 57.0% (61/107) of cases. Bystander cardiopulmonary resuscitation (CPR) was performed in 91.3% (21/23) and 68.6% (48/70) of cases of cardiac/respiratory arrest from drowning in public and private pools, respectively; the rate of bystander CPR was higher when a lifeguard was present (88.5%, 23/26 vs. 68.7%, 46/67). The majority (72.0%, 77/107) of drowning incidents occurred in private pools, most of which had no lifeguards present.

CONCLUSIONTo our knowledge, this study was the first in Singapore to examine data from emergency medical services. Since the majority of incidents occurred in private pools without lifeguards, it is recommended that a lifeguard be present at every pool. For pools that are too small to justify mandatory lifeguard presence, safety measures, such as guidelines for pool design and pool fencing with latched gates, may be considered. As strict enforcement may not be possible, public education and parental vigilance remain vital.

Objective: To investigate variations in the effects of prehospital advanced airway management (AAM) on outcomes of out-of-hospital cardiac arrest (OHCA) patients according to regional emergency medical service (EMS) systems in four Asian cities. Methods: We enrolled adult patients with EMS-treated OHCA of presumed cardiac origin between 2012 and 2014 from Osaka (Japan), Seoul (Republic of Korea), Singapore (Singapore), and Taipei (Taiwan). The main exposure variable was prehospital AAM. The primary endpoint was neurological recovery. We compared outcomes between the prehospital AAM and non-AAM groups using multivariable logistic regression with an interaction term between prehospital AAM and the four Asian cities. Results: A total of 16,510 patients were included in the final analyses. The rates of prehospital AAM varied among Osaka, Seoul, Singapore, and Taipei (65.0%, 19.2%, 84.9%, and 34.1%, respectively). The non-AAM group showed better outcomes than the AAM group (adjusted odds ratio [aOR] for neurological recovery 0.30; 95% confidence interval [CI], 0.24–0.38]). In the interaction model for neurological recovery, the aORs for AAM in Osaka and Singapore were 0.12 (95% CI, 0.06–0.26) and 0.21 (95% CI, 0.16–0.28), respectively. In Seoul and Taipei, the association between prehospital AAM and neurological recovery was not significant (aOR 0.58 [95% CI, 0.31–1.10] and 0.79 [95% CI, 0.52–1.20], respectively). The interaction between prehospital AAM and region was significant (P=0.01). Conclusion The effects of prehospital AAM on outcomes of OHCA patients differed according to regional variability in the EMS systems.

The role of the dispatch centre has increasingly become a focus of attention in cardiac arrest resuscitation. The dispatch centre is part of the first link in the chain of survival because without the initiation of early access, the rest of the chain is irrelevant. The influence of dispatch can also extend to the initiation of bystander cardiopulmonary resuscitation, early defibrillation and the rapid dispatch of emergency ambulances. The new International Liaison Committee on Resuscitation, the American Heart Association and, especially, the European Resuscitation Council 2015 guidelines have been increasing their emphasis on dispatch as the key to improving out-of-hospital cardiac arrest survival.

INTRODUCTIONPrompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) and defibrillation is necessary for good outcomes from out-of-hospital cardiac arrest (OHCA). This study aims to describe the recognition and treatment of OHCA in patients conveyed by non-emergency ambulance services (EAS) in Singapore.

MATERIALS AND METHODSThis is a multi-centre, retrospective chart review, of cases presenting to public emergency departments (EDs), conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. The study was from October 2002 to August 2009. The following variables were examined: ability to recognise cardiac arrest, whether CPR was carried out by the ambulance crew and whether an automated external defibrillator (AED) was applied.

RESULTSEighty-six patients were conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. Mean age was 63 years (SD 21.8), 70.9% were males. A total of 53.5% of arrests occurred in the ambulance while 70.9% were found to be asystolic upon ED arrival. Seven patients had a known terminal illness. Survival to discharge was 3.5%. Cardiac arrest went unrecognised by the ambulance crew in 38 patients (44.2%). CPR was performed in 35 patients (40.7%) of the 86 patients and AED was applied in only 10 patients (11.6%).

CONCLUSIONWe found inadequate recognition and delayed initiation of treatment for OHCA. Possible reasons include a lack of training in patient monitoring and detection of cardiac arrest, lack of CPR training, lack of confidence in performing CPR, lack of AEDs on ambulances and lack of training in their use.

Aged ; Aged, 80 and over ; Ambulances ; Cardiopulmonary Resuscitation ; standards ; Electric Countershock ; standards ; Emergency Medical Services ; standards ; Female ; Humans ; Male ; Middle Aged ; Out-of-Hospital Cardiac Arrest ; diagnosis ; therapy ; Retrospective Studies ; Singapore ; Transportation of Patients ; standards

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore. METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique. RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01). CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

INTRODUCTION: Hospital-based resuscitation interventions, such as therapeutic temperature management (TTM), emergency percutaneous coronary intervention (PCI) and extracorporeal membrane oxygenation (ECMO) can improve outcomes in out-of-hospital cardiac arrest (OHCA). We investigated post-resuscitation interventions and hospital characteristics on OHCA outcomes across public hospitals in Singapore over a 9-year period. METHODS: This was a prospective cohort study of all OHCA cases that presented to 6 hospitals in Singapore from 2010 to 2018. Data were extracted from the Pan-Asian Resuscitation Outcomes Study Clinical Research Network (PAROS CRN) registry. We excluded patients younger than 18 years or were dead on arrival at the emergency department. The outcomes were 30-day survival post-arrest, survival to admission, and neurological outcome. RESULTS: The study analysed 17,735 cases. There was an increasing rate of provision of TTM, emergency PCI and ECMO (P<0.001) in hospitals, and a positive trend of survival outcomes (P<0.001). Relative to hospital F, hospitals B and C had lower provision rates of TTM (≤5.2%). ECMO rate was consistently <1% in all hospitals except hospital F. Hospitals A, B, C, E had <6.5% rates of provision of emergency PCI. Relative to hospital F, OHCA cases from hospitals A, B and C had lower odds of 30-day survival (adjusted odds ratio [aOR]<1; P<0.05 for hospitals A-C) and lower odds of good neurological outcomes (aOR<1; P<0.05 for hospitals A-C). OHCA cases from academic hospitals had higher odds ratio (OR) of 30-day survival (OR 1.3, 95% CI 1.1-1.5) than cases from hospitals without an academic status. CONCLUSION Post-resuscitation interventions for OHCA increased across all hospitals in Singapore from 2010 to 2018, correlating with survival rates. The academic status of hospitals was associated with improved survival.
Hospitals, Public ; Humans ; Out-of-Hospital Cardiac Arrest/therapy* ; Percutaneous Coronary Intervention ; Prospective Studies ; Singapore/epidemiology*