Association of COVID-19 'circuit breaker' with higher rates of elderly trauma admissions.

Introduction: In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus emerged and caused a worldwide pandemic, leading to measures being imposed by many countries to reduce its transmission. Singapore implemented the 'circuit breaker', which restricted all movements except for access to necessities and healthcare services. We aimed to investigate the impact of lockdown measures on the pattern of trauma and its effects. Methods: An observational, retrospective, single-centre descriptive study was conducted using the trauma registry in Singapore General Hospital. It included patients above 18 years old who presented to the emergency department with trauma and were subsequently admitted. Patients admitted from 1 February 2020 to 31 July 2020 and those admitted during the same timeframe in 2019 were studied. Subgroup analyses were performed for patients aged ≥65 years and those <65 years. Results: A total of 1,037 patients were included for analysis. A 17.6% increase in trauma presentations was seen from 2019 to 2020. Patients aged ≥65 years accounted for the rise in admissions. The predominant mechanism of injury was falls at home for older patients and vehicular accidents in patients <65 years. There were no significant differences in injury severity score, intensive care/high-dependency unit admission rates, length of stay, mortality rate, and subsequent need for inpatient rehabilitation. Conclusion: Our study provided information on differences in trauma presentations before and during the COVID-19 pandemic. Further studies are required to better inform on additional precautionary measures needed to reduce trauma and improve safety during future lockdowns and pandemics.

Clinical evaluation of the use of laryngeal tube versus laryngeal mask airway for out-of-hospital cardiac arrest by paramedics in Singapore.

INTRODUCTION: It remains unclear which advanced airway device has better placement success and fewer adverse events in out-of-hospital cardiac arrests (OHCAs). This study aimed to evaluate the efficacy of the VBM laryngeal tube (LT) against the laryngeal mask airway (LMA) in OHCAs managed by emergency ambulances in Singapore. METHODS: This was a real-world, prospective, cluster-randomised crossover study. All OHCA patients above 13 years of age who were suitable for resuscitation were randomised to receive either LT or LMA. The primary outcome was placement success. Per-protocol analysis was performed, and the association between outcomes and airway device group was compared using multivariate binomial logistic regression analysis. RESULTS: Of 965 patients with OHCAs from March 2016 to January 2018, 905 met the inclusion criteria, of whom 502 (55.5%) were randomised to receive LT while 403 (44.5%) were randomised to receive LMA. Only 174 patients in the LT group actually received the device owing to noncompliance. Placement success rate for LT was lower than for LMA (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.90). Complications were more likely when using LT (OR 2.82,0 95% CI 1.64-4.86). Adjusted OR for prehospital return of spontaneous circulation (ROSC) was similar in both groups. A modified intention-to-treat analysis showed similar outcomes to the per-protocol analysis between the groups. CONCLUSION: LT was associated with poorer placement success and higher complication rates than LMA. The likelihood of prehospital ROSC was similar between the two groups. Familiarity bias and a low compliance rate to LT were the main limitations of this study.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE).

BACKGROUND: Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED. AIM: To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services. METHODS: We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart. RESULTS: After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388). CONCLUSION: Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.

Compliance With Asthma Guidelines and Association With Outcomes in the Emergency Department of a Tertiary Care Teaching Hospital.

BACKGROUND: Despite the existence of guidelines for treating acute asthma patients in the emergency department (ED), compliance is often poor. We aimed to examine the compliance to treatment guidelines for asthma at our tertiary care teaching hospital's ED and association with re-attendance rates. METHODS: We performed a retrospective analysis of electronic patient records of patients above 16 years old who presented to our ED with a primary diagnosis of asthma over a 6 month period in 2012. Patient demographics such as age, gender, history of previous intubations and hospitalisations were reviewed, as were the treatment administered during the ED visit and on discharge. Concordance of treatment was compared with the National Asthma Education and Prevention Program's Expert Panel Report 3 (NAEPP EPR3) guidelines. Re-attendance rates to our ED within one year were then analysed. RESULTS: A total of 552 patients were included in the study. We found that 151 (27.4%) of patients reattended within the year, 35 (6.3%) returned more than twice. Low compliance to the EPR3 guidelines (p = 0.005), age of between 41 and 60 (p = 0.049), previous hospitalisations for asthma (p < 0.001) and non-use of recommended systemic corticosteroids (p = 0.020) in the ED predicted a higher re-attendance rate. Follow up care and medications on discharge were not signifi cant factors. CONCLUSION: Low compliance to recommended treatment by established guidelines is associated with higher re-attendance, as are middle age and previous hospitalisations. Besides managing pressures of time and resource limitations in the ED, an increased awareness of guidelines amongst doctors will improve asthma care.

A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture.

BACKGROUND: Acupuncture is a form of traditional Chinese medicine being increasingly used as complementary therapy in many countries. It is relatively safe and rarely associated with deep infections. CASE PRESENTATION: In this case report, we describe a middle-aged Chinese patient who presented acutely to our emergency department with cauda equina syndrome secondary to acupuncture-related epidural abscesses, which were treated with surgical decompression and intravenous antibiotics. We also present a review of case reports of this rare condition in available literature. CONCLUSION: Emergency physicians should be aware that spinal abscesses may occur after acupuncture, with a broad spectrum of clinical presentations. If a history of recent acupuncture over the symptomatic area is elicited, a high index of suspicion should be maintained and appropriate imaging performed to establish the diagnosis. Treatment is directed by a number of factors, such as severity and duration of neurological deficit and progression of symptoms.