Headache in the Emergency Department: A Multicenter Observational Study from Singapore.

Background and Objectives: There is scarce data about the epidemiology, clinical features, investigations, diagnosis, treatment, and outcome in patients attending Singapore emergency departments (EDs) with nontraumatic headache. We sought to describe these characteristics of adult patients presenting to the ED with a primary complaint of headache. Materials and Methods: We performed a cross-sectional study on adult patients with nontraumatic headache over 4 consecutive weeks from 18 March 2019 to 14 April 2019 across four EDs in Singapore. Exclusion criteria were history of head trauma within 48 h of presentation, missing records, interhospital transfers, representation with the same headache as a recent previous visit and headache as an associated symptom. Results: During the study period, 579 patients (representing 1.8% of the total ED census) comprising 55.3% males and with a median age of 36 years presented to the four Singapore EDs with a primary complaint of nontraumatic headache. Paracetamol (41.5%), non-steroidal anti-inflammatory drugs (34.4%) and tramadol (31.5%) were the three commonest analgesics used either singly or in combination. Prochlorperazine (22.9%) and metoclopramide (17.4%) were frequent anti-emetic adjuncts. One-third of patients had computed tomography of the brain performed, which found abnormalities among 20.9% of them. ED diagnoses of primary headache conditions were made in 73.6% of patients. Conclusions: Primary headaches constituted most ED headache diagnoses. ED imaging of selected patients yielded a relatively high pick-up rate for significant intracranial abnormalities. Opioid use for symptomatic relief of headaches in the ED was found to be high, underscoring the need for improvement in headache analgesia relief practices in the ED.

Predictive performance of emergency department-specific variables on COVID-19 pneumonia.

Introduction: The majority of patients with COVID-19 infection do not progress to pneumonia. We report emergency department (ED)-specific variables and evaluate their predictive performance on diagnosis of pneumonia, intensive care unit (ICU) admission and death. Methods: This was a retrospective, single-centre cohort study of confirmed COVID-19 patients admitted to a Singapore tertiary hospital. Primary outcome was diagnosis of COVID-19 pneumonia. Secondary outcomes were ICU admission and/or death. Multivariate logistic regression was used to analyse the predictive performance of ED-specific variables. Accuracy of continuous variables was measured by area under receiver operating characteristic (ROC) curve. Results: 294 patients were included. Patients with pneumonia were older (52.0 years, P < 0.001) and had higher C-reactive protein (CRP; 33.8 mg/L, P < 0.001). Patients with indeterminate chest radiograph (CRX) findings were at risk of pneumonia vs. patients with normal CRX (37.5% vs. 4.3%, P < 0.001). Patients admitted to ICU were older (60.0 years, P < 0.001) and had higher CRP (40.0 mg/L, P < 0.001). Diagnosis of COVID-19 pneumonia was associated with ICU admission and death (30.0% vs 0.39%, P < 0.001). Multivariate logistic regression analysis showed that age (aOR 1.07, P = 0.049), CRP (aOR 1.05, P = 0.006) and CRX findings (aOR 50.00, P < 0.001) had increased odds of pneumonia. ROC curve analysis showed that CRP of 23.3 mg/L was the optimal cut-off for predicting pneumonia. Conclusion: Older age, higher CRP and CRX findings are associated with COVID-19 pneumonia, ICU admission and death. Prospective studies should be undertaken to validate these findings.

Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study.

BACKGROUND: An increasing number of patients who present to emergency departments are at their end-of-life phase and have significant palliative care needs such as in symptom control for pain and dyspnoea. Evaluating quality of care provided is imperative, yet there is no suitable tool validated in the emergency and Asian settings. We aim to examine the face and construct validity, and reliability of a newly developed questionnaire, Care of the Dying Evaluation - Emergency Medicine, for measuring the quality of end-of-life care in an Asian emergency context. METHODS: A mixed methods pilot study was conducted. Participants composed of the next-of-kin to thirty dying patients who presented to the emergency departments of three public hospitals in Singapore. Qualitative evaluation, using cognitive "think-aloud" interviews, and quantitative analysis were employed. Percentage agreement and κ statistic were measured to evaluate temporal stability of the questionnaire. Cronbach's α and item-total correlations were used to assess internal consistency within the constructs. Confirmatory factor analysis was performed for construct validity. RESULTS: All participants reported clear understanding of the questionnaire with no ambiguity; a minority felt the questions caused emotional distress (7/30, 23.3%). The questions showed moderate to good test-retest reliability. Internal consistencies within the constructs were good for "ENVIRONMENT" and "CARE", and moderate for "COMMUNICATION". Factor loadings range from 0.40 to 0.99. CONCLUSIONS: The Care of the Dying Evaluation - Emergency Medicine questionnaire may be valid and reliable for use in an Asian emergency setting. Our prospective multicentre study using this evaluation tool may provide more insight on the quality of care rendered to dying patients and identify areas for improvement. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03906747).

End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study.

BACKGROUND: Patients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet the environment and physicians in ED are not traditionally equipped or trained to provide palliative care. This multicentre study aims to measure the current quality of EOL care in ED to identify gaps, formulate improvements and implement the improved EOL care protocol. We shall also evaluate healthcare resource utilisation and its associated costs. METHODS AND ANALYSIS: This study employs a quasiexperimental interrupted time series design using both qualitative and quantitative methods, involving the EDs of three tertiary hospitals in Singapore, over a period of 3 years. There are five phases in this study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to validate the CODE questionnaire in the local context; (3) preimplementation phase; (4) focus group discussions (FGDs); and (5) postimplementation phase. In the prospective cohort, patients who are actively dying or have high likelihood of mortality this admission, and whose goal of care is palliation, will be eligible for inclusion. At least 140 patients will be recruited for each preimplementation and postimplementation phase. There will be face-to-face interviews with patients' family members, review of medical records and self-administered staff survey to evaluate existing knowledge and confidence. The FGDs will involve hospital and community healthcare providers. Data obtained from the retrospective cohort, preimplementation phase and FGDs will be used to guide prospective improvement and protocol changes. Patient, family and staff relevant outcomes from these changes will be measured using time series regression. ETHICS AND DISSEMINATION: The study protocol has been reviewed and ethics approval obtained from the National Healthcare Group Domain Specific Review Board, Singapore. The results from this study will be actively disseminated through manuscript publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03906747.

Fatal lightning strikes in Malaysia.

Lightning strike is a natural phenomenon with potentially devastating effects and represents one of the important causes of deaths from environmental phenomena. Almost every organ system may be affected as lightning current passes through the human body taking the shortest pathways between the contact points. A 10 years retrospective study (1996-2005) was conducted at University Hospital Kuala Lumpur (20 cases) also including cases during last 3 years from Hospital Tengku Ampuan Rahimah, Klang (7 cases) from the autopsy reports at Forensic Pathology Units of these 2 hospitals. Both these hospitals are attached to University of Malaya. There were 27 fatal cases of lightning strike with male preponderance(92.59%) and male to female ratio of 12.5:1. Majority of victims of lightning strike were from the age group between 30 and 39 years old. Most of the victims were foreign workers. Indonesians workers contributed to 59.26% of overall cases. Majority of them were construction workers who attributed i.e.11 of 27 cases (40.74%). Most of the victims were brought in dead (37.04%). In majority of the cases the lightning incidence occurred in the evenings, with the frequency of 15 of 27 cases (62.5%). The month of December represented with the highest number of cases (5 cases of 23 cases); 2004 had the highest incidence of lightning strike which was 5 (19.23%). Lightning strike incidence occurred when victims had taken shelter (25.9%) under trees or shades. Lightning strike in open areas occurred in 10 of 27 cases (37.0%). Head and neck were the most commonly affected sites with the incidence of 77.78% and 74% respectively in all the victims. Only 29.63% of the cases presented with ear bleeding.