Patient, staff empowerment and hand hygiene bundle improved and sustained hand hygiene in hospital wards.

AIM: We piloted a hand hygiene (HH) project in a ward, focusing on World Health Organization moments 1 and 4. Our aim was to design highly reliable interventions to achieve >90% compliance. METHODS: Baseline HH compliance was 57 and 67% for moments 1, 4, respectively, in 2015. After the pilot ward showed sustained improvement, we launched the 'HH bundle' throughout the hospital. This included: (i) appointment of HH champions; (ii) verbal/visual bedside reminders; (iii) patient empowerment; (iv) hand moisturisers; (v) tagging near-empty handrub (HR) bottles. Other hospital-wide initiatives included: (vi) Smartphone application for auditing; (vii) 'Speak up for Patient Safety' Campaign in 2017 for staff empowerment; (viii) making HH a key performance indicator. RESULTS: Overall HH compliance increased from a baseline median of 79.6-92.6% in end-2019. Moments 1 and 4 improved from 71 to 92.7% and from 77.6 to 93.2%, respectively. Combined HR and hand wash consumption increased from a baseline median of 82.6 ml/patient day (PD) to 109.2 mL/PD. Health-care-associated rotavirus infections decreased from a baseline median of 4.5 per 10 000 PDs to 1.5 per 10 000 PDs over time. CONCLUSIONS: The 'HH Bundle' of appointing HH champions, active reminders and feedback, patient education and empowerment, availability of hand moisturisers, tagging near-empty hand rub bottles together with hospital-wide initiatives including financial incentives and the 'Speak Up for Patient Safety' campaign successfully improved the overall HH compliance to >90%. These interventions were highly reliable, sustained over 4 years and also reduced health-care-associated rotavirus infection rates.

Novel Coronavirus 2019 Transmission Risk in Educational Settings.

Transmission risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in schools is unknown. Our investigations, especially in preschools, could not detect SARS-CoV-2 transmission despite screening of symptomatic and asymptomatic children. The data suggest that children are not the primary drivers of SARS-CoV-2 transmission in schools and could help inform exit strategies for lifting of lockdowns.

Evaluation of three paediatric weight estimation methods in Singapore.

AIM: Rapid paediatric weight estimation methods in the emergency setting have not been evaluated for South East Asian children. This study aims to assess the accuracy and precision of three such methods in Singapore children: Broselow-Luten (BL) tape, Advanced Paediatric Life Support (APLS) (estimated weight (kg) = 2 (age + 4)) and Luscombe (estimated weight (kg) = 3 (age) + 7) formulae. METHODS: We recruited 875 patients aged 1-10 years in a Paediatric Emergency Department in Singapore over a 2-month period. For each patient, true weight and height were determined. True height was cross-referenced to the BL tape markings and used to derive estimated weight (virtual BL tape method), while patient's round-down age (in years) was used to derive estimated weights using APLS and Luscombe formulae, respectively. The percentage difference between the true and estimated weights was calculated. For each method, the bias and extent of agreement were quantified using Bland-Altman method (mean percentage difference (MPD) and 95% limits of agreement (LOA)). The proportion of weight estimates within 10% of true weight (p10) was determined. RESULTS: The BL tape method marginally underestimated weights (MPD +0.6%; 95% LOA -26.8% to +28.1%; p10 58.9%). The APLS formula underestimated weights (MPD +7.6%; 95% LOA -26.5% to +41.7%; p10 45.7%). The Luscombe formula overestimated weights (MPD -7.4%; 95% LOA -51.0% to +36.2%; p10 37.7%). CONCLUSIONS: Of the three methods we evaluated, the BL tape method provided the most accurate and precise weight estimation for Singapore children. The APLS and Luscombe formulae underestimated and overestimated the children's weights, respectively, and were considerably less precise.

Bony presentations of childhood haematological malignancy to the emergency room.

AIM: Bony complaints are well-recognised symptoms of childhood haematological malignancy. However, this elusive symptom complex of haematological malignancy is not easily recognised in the emergency room (ER) where musculoskeletal problems are frequent. This study reviews bony complaints of childhood haematological malignancy in the ER. METHODS: This was a retrospective study of 148 children diagnosed with haematological malignancy between March 2002 and February 2007. RESULTS: Twenty-one cases (14.2%) presented with bony complaints to the ER within 3 months prior diagnosis of malignancy. The median age was 5.1 years, and majority (90.5%) had acute lymphoblastic leukaemia. Fifteen cases were undiagnosed for malignancy at first visit; diagnoses included pulled elbow, lower limb sprain and septic arthritis, with 21 days median time to correct diagnosis. In this undiagnosed group, history of trauma, fever, multiple bony site involvement, normal radiography and blood counts were common. Undiagnosed cases were referred to orthopaedics, paediatrics, rheumatology or the general practitioner, hospitalised or discharged without follow-up. CONCLUSION: The diagnosis of childhood haematological malignancy with first bony presentation to the ER was challenging, with a high prevalence of 71.4% undiagnosed cases at first visit. We highlight the common misdiagnoses because failure to correctly diagnose could delay timely institution of treatment. Trauma or normal investigations do not exclude an underlying haematological malignancy. This rare diagnosis in the ER should always be considered when challenged with recurrent bony complaints.

Pitfalls in paediatric appendicitis: Highlighting common clinical features of missed cases.

OBJECTIVE: Missed cases of paediatric appendicitis lead to a delay in diagnosis and increased complications during the subsequent surgery. We aim to identify the common clinical features of such cases at the time of first hospital attendance. METHODS: Case records of patients with a missed diagnosis were reviewed retrospectively, documenting the presentation, preliminary investigations, initial diagnosis and eventual outcome. RESULTS: Thirty-nine patients fitted our criteria over a 2-year and 5-month period. The rate of "missed appendicitis" was 7%. The commonest symptoms and signs were that of nausea and vomiting (74.4%), abdominal pain (74.4%) and fever (61.5%). The site of abdominal pain was rarely in the right iliac fossa (5.1%). The two commonest diagnoses made at first presentation was that of gastroenteritis (51.3%) and constipation (25.6%). Twenty patients (51.3%) were initially discharged home. Compared to those initially admitted, more of those initially discharged home underwent surgery delayed beyond 24 hours from first presentation. CONCLUSION: The paucity of symptoms and signs in the right lower quadrant does not exclude appendicitis. Gastroenteritis and colic constipation are the greatest masqueraders of paediatric appendicitis. A high index of suspicion, therefore, is necessary to avoid wrongful discharge altogether.