COVID-19 Close Contact Management: An Evolution of Operations Harnessing the Digital Edge.

Singapore, like many other nations globally, had to contend with significant caseloads arising from the Coronavirus disease (COVID-19) pandemic. This paper focuses on using technology as an intervention for pandemic management. With scant scientific evidence on effective medications and vaccinations (i.e., pharmaceutical interventions) initially, disease containment strategies predominated during the early phases. Non-pharmaceutical interventions were critical in slowing disease transmission and preventing public healthcare institutions from being overwhelmed. Such interventions could be broadly divided into case-based interventions (e.g., contact tracing and quarantining of close contacts) and population-based measures (e.g., mask use and social distancing). The paper describes Singapore's experience in the operational implementation of contact-based interventions, and illustrates how harnessing the digital edge enabled fast, accurate, resource-efficient, and flexible execution of ground operations. Singapore applied digital technology and developed an integrated system to facilitate issuance and acknowledgement of quarantine orders, submission of COVID-19 test results, and collection of antigen rapid test kits at the population level. Data was obtained from this proprietary centralised, automated platform. The paper demonstrates how such simple, yet elegant systems could have a direct impact on disease transmission in an outbreak setting and on population health. Moving forward, it is recommended that technology and digital solutions feature prominently in work process designs beyond COVID-19 such as in the management of emerging infectious diseases and non-communicable diseases.

Assessment of COVID-19 Positive Rates Amongst COVID-19 Close Contacts Through the Health Risk Warning System.

From 6 Jan 22 to 17 Feb 22, a total of 729,367 close contacts classified into four distinct groups (i.e., household, social, school and nursing/ welfare home contacts) were managed by the Health Risk Warning system. High COVID-19-positive rates were demonstrated amongst household contacts, i.e., 10.9% (37,220/342,302) were detected via antigen rapid test kits and 56.5% (4,952/8,767) were detected via polymerase chain reaction testing. Household contacts represent the highest risk of being infected by virtue of the sustained close-proximity interactions in the household setting. Social, school and nursing/ welfare home contacts continue to remain at-risk groups for close monitoring. At a population level, household and symptomatic close contacts should be the groups of focus in the early phases of the pandemic, including future potential waves involving COVID-19 variants of concern.

Enhanced Monitoring System to Better Monitor High-Risk COVID-19 Patients.

Telemedicine (TM) is a useful tool to extend medical care during a pandemic. TM was extensively utilized in Singapore during the COVID-19 pandemic as part of the Nation's COVID-19 healthcare strategy. Patients were risk stratified to prioritize limited healthcare resources and the Telemedicine Allocation Reconciliation System (TMARS) was adapted to monitor and manage limited TM resources. High-Risk patients (Protocol 1) had an escalation rate of 4.87%, compared to the non-High-Risk patients' 0.002% and TM doctors spent an average of six hours to complete one tele-consultation. In order to optimize the efficiency of the TM system, an enhanced monitoring system was implemented in March 2022. The intent was to focus monitoring efforts on the High-Risk patients. High-Risk patients reporting sick for the first time were prioritized to receive tele-consultations through this system. With the aid of a data-driven dashboard, the Operations Control and Monitoring team (OCM) was able to closely monitor the performance of the various TM providers (TMPs), sent them timely reminders and re-assigned patients to other TMPs when the requisite turnaround time was not met. Implementing the enhanced monitoring system resulted in a significant reduction in the average time taken to provide tele-consultations. After 3 months of implementation, the percentages of consultations completed within two hours were raised from 75.7% (February 2022) to 96.8% (May 2022), greatly increasing productivity and efficiency.

A prospective comparative study on the effectiveness of two different non-adherent polyurethane dressings on split-thickness skin graft donor sites.

AIM: To analyze differences in re-epithelization, exudate absorbency, ease and pain on dressing removal between ALLEVYN™ Non-Adhesive and Betaplast™ N. METHODOLOGY: Patients admitted to the general ward undergoing split skin grafting were recruited. Allevyn and Betaplast were applied on the donor site. Exudate absorption was assessed daily using an absorbency grading chart. Dressing change was done on post-operative day five. Ease of dressing removal and pain score using the Wong-Baker Pain Scale was assessed. The percentage of re-epithelization for each dressing was assessed. RESULTS: 30 patients were recruited. There was a statistically significant difference in exudate absorption on post-operative day 3 (z = -2.006, p = 0.045, T = 236) and post-operative day 4 (z = -2.026, p = 0.0143, T = 188), pain score (z = -2.861, p = 0.004, T = 180), ease of removal (z = -2.668, p = 0.008, T = 126) and re-epithelization (z = -2.566, p = 0.009, T = 336) between Betaplast and Allevyn. CONCLUSION: Betaplast may have faster re-epithelization, better exudate absorption, and is easier to remove while minimizing discomfort as compared to Allevyn.

Keratin-Alginate Sponges Support Healing of Partial-Thickness Burns.

Deep partial-thickness burns damage most of the dermis and can cause severe pain, scarring, and mortality if left untreated. This study serves to evaluate the effectiveness of crosslinked keratin-alginate composite sponges as dermal substitutes for deep partial-thickness burns. Crosslinked keratin-alginate sponges were tested for the ability to support human dermal fibroblasts in vitro and to support the closure and healing of partial-thickness burn wounds in Sus scrofa pigs. Keratin-alginate composite sponges supported the enhanced proliferation of human dermal fibroblasts compared to alginate-only sponges and exhibited decreased contraction in vitro when compared to keratin only sponges. As dermal substitutes in vivo, the sponges supported the expression of keratin 14, alpha-smooth muscle actin, and collagen IV within wound sites, comparable to collagen sponges. Keratin-alginate composite sponges supported the regeneration of basement membranes in the wounds more than in collagen-treated wounds and non-grafted controls, suggesting the subsequent development of pathological scar tissues may be minimized. Results from this study indicate that crosslinked keratin-alginate sponges are suitable alternative dermal substitutes for clinical applications in wound healing and skin regeneration.

An Outcomes Study on the Effects of the Singapore General Hospital Burns Protocol.

INTRODUCTION: The Singapore General Hospital Burns Protocol was implemented in May 2014 to standardize treatment for all burns patients, incorporate new techniques and materials, and streamline the processes and workflow of burns management. This study aims to analyze the effects of the Burns Protocol 2 years after its implementation. METHODS: Using a REDCap electronic database, all burns patients admitted from May 2013 to April 2016 were included in the study. The historical preimplementation control group composed of patients admitted from May 2013 to April 2014 (n = 96). The postimplementation prospective study cohort consisted of patients admitted from May 2014 to April 2016 (n = 243). Details of the patients collected included age, sex, comorbidities, total body surface area (TBSA) burns, time until surgery, number of surgeries, number of positive tissue and blood cultures, and length of hospital stay. RESULTS: There was no statistically significant difference in the demographics of both groups. The study group had a statistically significant shorter time to surgery compared with the control group (20.8 vs 38.1, P < 0.0001). The study group also averaged fewer surgeries performed (1.96 vs 2.29, P = 0.285), which, after accounting for the extent of burns, was statistically significant (number of surgeries/TBSA, 0.324 vs 0.506; P = 0.0499). The study group also had significantly shorter length of stay (12.5 vs 16.8, P = 0.0273), a shorter length of stay/TBSA burns (0.874 vs 1.342, P = 0.0101), and fewer positive tissue cultures (0.6 vs 1.3, P = 0.0003). The study group also trended toward fewer positive blood culture results (0.09 vs 0.35, P = 0.0593), although the difference was just shy of statistical significance. CONCLUSIONS: The new Singapore General Hospital Burns Protocol had revolutionized Singapore burns care by introducing a streamlined, multidisciplinary burns management, resulting in improved patient outcomes, lowered health care costs, and improved system resource use.

Impact of a Newly Implemented Burn Protocol on Surgically Managed Partial Thickness Burns at a Specialized Burns Center in Singapore.

OBJECTIVE: This study evaluated the impact of a newly implemented protocol for superficial to mid-dermal partial thickness burns which involves early surgery and rapid coverage with biosynthetic dressing in a specialized national burns center in Singapore. METHODS: Consecutive patients with 5% or greater total body surface area (TBSA) superficial to mid-dermal partial thickness burns injury admitted to the Burns Centre at the Singapore General Hospital between August and December 2014 for surgery within 48 hours of injury were prospectively recruited into the study to form the protocol group. Comparable historical cases from the year 2013 retrieved from the burns center audit database were used to form the historical control group. Demographics (age, sex), type and depth of burns, %TBSA burnt, number of operative sessions, and length of stay were recorded for each patient of both cohorts. RESULTS: Thirty-nine burns patients managed under the new protocol were compared with historical control (n = 39) comparable in age and extensiveness of burns. A significantly shorter length of stay (P < 0.05) per TBSA burns was observed in the new protocol group (0.74 day/%TBSA) versus historical control (1.55 day/%TBSA). Fewer operative sessions were needed under the new protocol for burns 10% or greater TBSA burns (P < 0.05). CONCLUSIONS: The authors report their promising experience with a newly implemented protocol for surgically managed burns patients which involves early surgery and appropriate use of biosynthetic dressing on superficial to mid-dermal partial thickness burns. Clinically, shorter lengths of stay, fewer operative sessions, and decreased need for skin grafting of burns patient were observed.

Achieving self-sufficiency in skin allograft: A Singapore experience.

AIM: This paper describes how Singapore achieved skin allograft self-sufficiency in 2017 by adopting 5 key strategies in 2012. BACKGROUND: Singapore General Hospital (SGH) established its own allograft recovery programme in 1998 but was still dependent on overseas allograft procurement. KEY STRATEGIES: RESULTS: The allograft recovery programme expanded from 4 to all 20 institutions. Donor referrals increased by 42.9% from 35 in 2014 to over 50 currently. Donor numbers increased by 210%, rising from 4.5 per year before 2015 to an average of 14 per year from 2015 to 2022. The total allografts recovered increased by 223%, climbing from 13,000 to 42,000 annually. Cryopreservation was adopted, extending shelf life to 5.5 years and doubling storage capacity to more than 140,000 cm2 in 2022. CONCLUSION: Singapore achieved skin allograft self-sufficiency with no overseas procurement since 2017.

The role of multiplatform messaging applications in burns care and rehabilitation: A systematic review.

BACKGROUND: Multiplatform messaging applications also referred to as cross-platform instant messaging play an important role in delivery of healthcare and education with its low cost, ease of use and accessibility. AIM: To evaluate the existing evidence regarding the use of multiplatform messaging applications in facilitating consultations and decision-making processes in the context of burns care, as well as to assess the impact of such applications on burns care and rehabilitation. METHOD: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PROSPERO protocol CRD42021265203. The CASP and JBI tools were used to evaluate the quality of the studies. Eight hundred fifty-three papers were retrieved from PubMed, CINAHL, Scopus, EMBASE and LILACS published up to July 2022 (updated August 2023) with no time restrictions applied. RESULTS: An analysis of the seven studies included in this review, inclusive of 16 Multiplatform messaging applications, revealed six themes. These encompassed the utilization of social media for directing and managing clinical practice, as a mode of communication, for evaluating the quality-of-care provision, for investigating available platforms and their technological features, measuring quality of life and for examining issues related to confidentiality. CONCLUSION: Multiplatform messaging applications offer a solution for individuals with burn injuries to stay in direct contact with burn specialist clinicians for their follow-up and subsequent rehabilitation phase of recovery.

Singapore's experience in managing the COVID-19 pandemic: Key lessons from the ground.

Singapore managed the COVID-19 pandemic in the past three years and gleaned valuable lessons on patient management when the public healthcare system was inundated with COVID-19 patients. There were several initiatives, which included setting up of community treatment facilities to help hospitals manage in-patient loads that did not require acute monitoring, leveraging telemedicine, and developing heuristics to sort patients based on their clinical disposition to various care pathways and to effectively manage patients of different medical needs. These initiatives were implemented in the second year of the epidemic in 2021 and did not include the dormitory-based migrant workers and migrant workers in the construction, maritime and production sectors who were under the care of the Assurance, Care and Engagement Group (ACE) in the Ministry of Manpower that had its own set of treatment management measures. The different care pathways ensured that patients received appropriate levels of care and allowed healthcare facilities to focus on more acute cases. In 2022 alone, 23,159 patients were discharged from community treatment facilities against the background of 1.9 million COVID-19 patients. These initiatives would not be possible without the oversight of an advisory board comprising senior leadership from the healthcare clusters and the Ministry of Health to align clinical governance with medical policies, and prompt and immense support from medical specialist panels. The strong public-private partnership forged in the process was instrumental in the successful operation of community facilities and implementation of patient care protocols, coupled with harnessing information technology and leveraging on emerging data to refine care protocols.

A simple mnemonic, B.U.R.N.S., for burns first aid.

INTRODUCTION: Burn injuries remain common in the world, with an average of more than thousands of cases requiring medical attention each year. Singapore sees an average of 220 burns admissions annually. Given the high number of burn cases in Singapore, the authors identified that there is a need for more public awareness on first aid burn treatment. Acute management of burns can improve eventual patient outcome. The authors devised a simple mnemonic that can be used in burns education for first aid treatment, intended to be taught to trained personnel, who will have the first contact with these burn patients. The aim of the study was to assess the viability of implementing this mnemonic, B.U.R.N.S, to facilitate first aid education for burns. MATERIAL AND METHODS: In this study, we presented this mnemonic as a poster to 30 full-time burn care medical professionals. Feedback was then obtained from this group of medical professionals and used to revise the mnemonic. The mnemonic was then subsequently taught to 400 medical professionals, who are predominantly involved in the pre-hospital management of burns. They are then asked to reiterate the mnemonic to test the ease of remembering the mnemonic. Objective feedback was obtained with a 5-point scoring system. RESULTS: The results indicated a significant improvement in burn first aid knowledge after the implementation of the mnemonic, from a score of 3.67-4.77, The content was deemed as appropriate and easy to understand and recall, and participants were able to reiterate the content, and will recommend this mnemonic to be used for burns teaching for first aid. CONCLUSION: The study results suggest that this B.U.R.N.S. mnemonic and visual aid is simple and easy to apply, especially for uniformed personnel, as these individuals may have the first contact with the burns victims, and it is important for them to render the appropriate burns first aid treatment. Overall, burns first aid awareness and education can be improved with the implementation of this mnemonic and poster. Moving forward, we aim to integrate the B.U.R.N.S. into educational programmes in professional institutions involved in responding to burns (medical and nursing schools of Singapore), as well as in schools and public institutions, for educational purpose to raise public awareness. We wish to also be able to do so on an international level when courses are conducted.

Nationwide implementation of a centralised telemedicine platform in Singapore to fight the COVID-19 pandemic.

INTRODUCTION: This study aims to share the experience of the Ministry of Health (Singapore) in deploying a centrally managed Telemedicine service to triage, and manage COVID-19 cases in the community during the COVID-19 Omicron wave. MATERIAL AND METHODS: Data from the deployed telemedicine system, Telemedicine Allocation and Reconciliation System, over a 14-week period (3 January 2022-10 April 2022) was analysed to determine the safety and efficacy of both the (i) National COVID-19 sorting logic algorithm and (ii) the use of a centralised telemedicine platform with privacy protection in a pandemic. RESULTS: There was a total of 47,754 children (aged 1-11 years old), 75,702 adolescents and adult patients (aged 12-69 years old) and 55,774 geriatric patients (aged > = 70 years old) who were directly managed by this platform. Amongst them, 64,961 were from the higher-risk special populations (pregnant, end-stage renal failure and immunocompromised and geriatric population).The total number of patients requiring escalations to public health institutions were 4212. This accounts for 1.32%, 3.00% and 2.35% of the children, teenagers and adults, and geriatric population respectively.

Applicability and benefits of telemedicine in the monitoring of monkeypox close contacts.

Monkeypox is a zoonotic disease caused by the monkeypox virus and classically presents as a vesicular rash accompanied by fever and lymphadenopathy. Singapore reported the first imported case of monkeypox infection on 21 June 2022, the first local unlinked case on 6 July 2022, and the first local linked case on 5 August 2022. Telemedicine was used in the management of monkeypox close contacts to (1) screen for the development of signs and symptoms consistent with monkeypox infection, (2) assess for successful post-exposure prophylaxis via direct visualisation of vaccination site morphological progression, (3) detect serious reactions arising from post-exposure prophylaxis administration, and (4) evaluate for deterioration in mental health status during the 21-day quarantine period. A case series of 13 close contacts who received post-exposure prophylaxis in the form of the ACAM2000 live Vaccinia virus preparation is presented, illustrating the safe and efficacious application of telemedicine in the clinical follow-up of quarantined close contacts throughout the 21-day incubation period, and post-exposure prophylaxis monitoring. Inherent limitations included difficulties in the assessment of sensitive areas such as the peri-genital and peri-anal regions and video quality-related issues.

Airway management in inhalation injury: a case series.

Inhalation injury is a serious consequence of a fire or an explosion, with potential airway compromise and respiratory complications. We present a case series of five patients with inhalational burns who presented to Singapore General Hospital and discuss our approach to their early management, including early evaluation and planning for the upper and lower airway, coexisting cutaneous burns, and monitoring their ICU (intensive care unit) severity of illness, sepsis and acute respiratory distress syndrome. All five patients suffered various grades of inhalation injury. The patients were initially assessed by nasolaryngoscopy, and three patients were prophylactically intubated before being sent to the emergency operating theatre for definitive airway and burns management with fibreoptic bronchoscopy. All patients were successfully extubated and discharged stable. Various complications can arise as a result of an inhalation injury. Based on our cases and literature review, we propose a standardised workflow for patients with inhalation injury.

Connexin 43 upregulation in burns promotes burn conversion through spread of apoptotic death signals.

BACKGROUND: Burn wounds continue to worsen after initial injury in a process known as burn conversion, which lasts about 3-5 days. It causes burn wounds to enlarge and deepen, leading to greater morbidity. Apoptosis is one of the factors contributing to the conversion of the zone of stasis into the zone of coagulation. Suppression of apoptosis has been associated with reducing burn conversion. Connexin 43 (Cx43) gap junctions facilitate the spread of apoptotic signals from dying cells to healthy neighbouring cells in injured tissues through the bystander effect. OBJECTIVES: The study is to understand the role of Cx43 in burn conversion. METHODS: In our study, 15 burn tissue samples were arranged into three groups as early (beginning of burn conversion), intermediate (extensive burn conversion) and late (established burn conversion) burns. RESULTS: We found a striking increase in the amount of Cx43 protein expressed in the dermal fibroblasts (identified with heat shock protein 47 (HSP47) staining) in the zone of stasis in early and intermediate burns. These dermal fibroblasts also express high levels of cleaved-Caspase 3 indicating on-going apoptosis. CONCLUSIONS: Our findings suggest that elevation of Cx43 may play an active role in burn conversion spreading apoptosis in the early and intermediate burn wound.

Burn center function during the COVID-19 pandemic: An international multi-center report of strategy and experience.

The novel coronavirus, SARS-CO V2 responsible for COVID-19 pandemic is rapidly escalating across the globe. Burn centers gearing for the pandemic must strike a balance between contributing to the pandemic response and preserving ongoing burn care in a safe and ethical fashion. The authors of the present communication represent seven burn centers from China, Singapore, Japan, Italy, Spain, the United Kingdom (UK), and the United States (US). Each center is located at a different point along the pandemic curve and serves different patient populations within their healthcare systems. We review our experience with the virus to date, our strategic approach to burn center function under these circumstances, and lessons learned. The purpose of this communication is to share experiences that will assist with continued preparations to help burn centers advocate for optimum burn care and overcome challenges as this pandemic continues.

Renal outcomes of intensive care burn patients in an Asian tertiary centre.

INTRODUCTION: Acute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with a high mortality rate of up to 80%. We aimed to establish the incidence, mortality rate, and factors related to mortality in adult patients with severe burn injury and AKI with renal replacement therapy (RRT) in Singapore. METHODS: We performed a retrospective cohort study of severely burned patients who were admitted to the Burns Intensive Care Unit (BICU) at the Singapore General Hospital (SGH) from January 2008 to December 2016. We compared patients with AKI with RRT who survived with those who did not survive. As there were changes in the protocol for burns management after 2013, we also compared patients with AKI with RRT who survived with non-survivors in each of the 2008-2012 and 2013-2016 cohorts. RESULTS: Data of 201 patients were studied. The incidence of AKI with RRT use in severe burn injury was 21.9% and their mortality rate was 50.0%. The non-survivors had significantly higher median burned total body surface area (p = 0.043), earlier AKI (p = 0.046), earlier use of RRT (p = 0.035), lower rate of renal recovery (p = <0.0001), higher rates of adult respiratory distress syndrome (ARDS) (p = 0.005) and shock with vasopressors (p = 0.009) compared to the survivors. The survival rate was 36.8% in the 2008-2012 cohort, but improved to 60.0% in the 2013-2016 cohort. In the 2008-2012 cohort, the non-survivors developed AKI earlier (day 0 admission vs. day 3 admission, p = 0.039), and were initiated on RRT at lower serum creatinine level (173.5 µmol/L vs. 254.0 µmol/L, p = 0.042), when compared to the survivors in this same cohort. On the other hand, there were no significant differences in the renal status and fluid balance parameters between the non-survivors and survivors in the 2013-2016 cohort. CONCLUSIONS: The incidence of AKI with RRT in the Singapore study cohort was high, but their mortality rate was relatively lower compared to other study cohorts. Severity of AKI and use of RRT were associated with poor prognosis. Large scale study is required to further study the risk factors for mortality in this group of patients and establish cause-and-effect relationship.