Continuing medical education during a pandemic: an academic institution's experience.

The COVID-19 pandemic has affected healthcare systems worldwide. The disruption to hospital routines has affected continuing medical education (CME) for specialty trainees (STs). We share our academic institution's experience in mitigating the disruption on the CME programme amidst the pandemic. Most specialty training programmes had switched to videoconferencing to maintain teaching. Some programmes also utilized small group teachings with precautions and e-learning modules. Surgical residencies were disproportionately affected due to reductions in elective procedures but some ways to provide continued surgical exposure include going through archived surgical videos with technical pointers from experienced faculty and usage of surgical simulators . We should adapt CME sessions to keep trainees up to date with core clinical competencies as they will continue to manage both COVID-19 and non-COVID-19 cases and this pandemic may last until year's end.

Medical education in Singapore.

Allopathic medical education in Singapore extends for more than a century from its simple beginnings. In recent times, changes have been rapid, both in undergraduate and postgraduate specialty medical training. Over the last decade, undergraduate medical education has increased from a single to three medical schools and the postgraduate training has expanded further by incorporating the Accreditation Council for Graduate Medical Education International framework. With these changes, the curricula, assessment systems, as well as teaching and learning approaches, with the use of technology-enhanced learning and program evaluation processes have expanded, largely based on best evidence medical education. To support these initiatives and the recent rapid expansion, most training institutions have incorporated faculty development programs, such as the Centre for Medical Education at the National University of Singapore.

Stress and burnout amongst mental health professionals in Singapore during Covid-19 endemicity.

The COVID-19 pandemic has exerted a huge emotional strain on mental health professionals (MHP) in Singapore. As Singapore transited into an endemic status, it is unclear whether the psychological strain has likewise lessened. The aims of this study were to investigate the levels of stress and burnout experienced by MHP working in a tertiary psychiatric hospital in Singapore during this phase of COVID-19 endemicity (2022) in comparison to the earlier pandemic years (2020 and 2021) and to identify factors which contribute to as well as ameliorate stress and burnout. A total of 282 MHP participated in an online survey in 2022, which included 2 validated measures, namely the Perceived Stress Scale and the Oldenburg Burnout Inventory (OLBI). Participants were also asked to rank factors that contributed the most to their stress and burnout. Between-group comparisons were conducted regarding stress and burnout levels among MHP across different demographic groupings and working contexts. In addition, OLBI data completed by MHP in 2020 and 2021 were extracted from 2 published studies, and trend analysis was conducted for the proportion of MHP meeting burnout threshold across 3 time points. We found that the proportion of MHP meeting burnout threshold in 2020, 2021 and 2022 were 76.9%, 87.6% and 77.9% respectively. Professional groups, age, years of experience and income groups were associated with stress and/or burnout. High clinical workload was ranked as the top factor that contributed to stress and burnout while flexible working arrangement was ranked as the top area for improvement so as to reduce stress and burnout. As such, policy makers and hospital management may want to focus on setting clear mental health targets and facilitate manageable clinical workload, build manpower resiliency, optimize resources and provide flexible work arrangements to alleviate stress and burnout among MHP.

Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department.

AIM: For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. METHODS: We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models. RESULTS: Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score. CONCLUSION: Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.

Prognostic performance of soluble urokinase plasminogen activator receptor for heart failure or mortality in Western and Asian patients with acute breathlessness.

AIMS: The performance of circulating soluble urokinase plasminogen activator receptor (suPAR) for predicting the composite endpoint of subsequent heart failure (HF) hospitalisation and/or death at 1 year was assessed in (i) patients with undifferentiated breathlessness, and generalisability was compared in (ii) disparate Western versus Asian sub-cohorts, and in (iii) the sub-cohort adjudicated with HF. METHODS AND RESULTS: Patients with acute breathlessness were recruited from the emergency departments in New Zealand (NZ, n = 612) and Singapore (n = 483). suPAR measured in the presentation samples was higher in patients incurring the endpoint (n = 281) compared with survivors (5.2 ng/mL vs 3.1 ng/mL, P < 0.0001). The discriminative power of suPAR for endpoint prediction was c-statistic of 0.77 in the combined population, but was superior in Singapore than NZ (c-statistic: 0.83 vs 0.71, P < 0.0001). Although the highest suPAR tertile (>4.37 ng/mL) was associated with risks of >4-fold in NZ, >20-fold in Singapore, and ≥3-fold in HF for incurring the outcome, there was no interaction between country and suPAR levels after adjustment. Multivariable analysis indicated suPAR to be robust in predicting HF/death at 1-year [hazard ratio: 1.9 (95% CI:1.7 to 2.0) per SD increase] and improved risk discrimination for outcome prediction in HF (∆0.06) and for those with NT-proBNP >1000 pg/mL (∆0.02). CONCLUSION: suPAR is a strong independent predictor of HF and/or death at 1 year in acutely breathless patients, in both Asian and Western cohorts, and in HF. suPAR may improve stratification of acutely breathless patients, and in acute HF, for risk of later onset of heart failure or mortality.

Circulating erythroferrone has diagnostic utility for acute decompensated heart failure in patients presenting with acute or worsening dyspnea.

Objectives: In dyspneic patients with atrial fibrillation (AF) or obesity, the diagnostic performance of NT-proBNP for acute heart failure is reduced. We evaluated the erythroblast derived protein erythroferrone (ERFE) as an ancillary biomarker for the diagnosis of acute decompensated heart failure (ADHF) in these comorbid subgroups in both Western and Asian populations. Methods: The diagnostic performance of ERFE (Intrinsic Lifesciences) and NT-proBNP (Roche Cobas e411) for ADHF was assessed in 479 New Zealand (NZ) and 475 Singapore (SG) patients presenting with breathlessness. Results: Plasma ERFE was higher in ADHF, compared with breathlessness from other causes, in both countries (NZ; 4.9 vs. 1.4 ng/ml, p < 0.001) and (SG; 4.2 vs. 0.4 ng/ml, p = 0.021). The receiver operating characteristic (ROC) areas under the curve (AUCs) for discrimination of ADHF were reduced in the NZ cohort compared to SG for ERFE (0.75 and 0.84, p = 0.007) and NT-proBNP (0.86 and 0.92, p = 0.004). Optimal cut-off points for ERFE yielded comparable sensitivity and positive predictive values in both cohorts, but slightly better specificity, negative predictive values and accuracy in SG compared with NZ. In patients with AF, the AUC decreased for ERFE in each cohort (NZ: 0.71, n = 105, SG: 0.61, n = 44) but increased in patients with obesity (NZ: 0.79, n = 150, SG: 0.87, n = 164). Conclusions: Circulating ERFE is higher in patients with ADHF than in other causes of new onset breathlessness with fair diagnostic utility, performing better in Asian than in Western patients. The diagnostic performance of ERFE is impaired in patients with AF but not patients with obesity.

Safety attitudes, burnout and well-being among healthcare workers during the COVID-19 pandemic: an Indo-Pacific regional cross-sectional study.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on the safety attitudes among healthcare workers (HCWs), as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety. Methods: A cross-sectional survey study utilising snowball sampling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory and Hospital Anxiety and Depression Scale. We performed multivariate mixed-model regression to assess independent associations with the SAQ total percentage agree rate (PAR). Results: We obtained 3,163 responses. The SAQ total PARs were found to be 35.7%, 15.0%, 51.0% and 3.3% among the respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest among respondents from India (70.9%-85.4% vs. 56.3%-63.6%, respectively). Multivariate analyses revealed that meeting burnout and depression thresholds and shifts lasting ≥12 h were significantly associated with lower SAQ total PAR. Conclusion: Addressing the factors contributing to high burnout and depression and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities during the pandemic.

Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis.

OBJECTIVE: This study aims to explore the risk factors and predictors involved in the missed diagnosis of acute aortic dissection (AAD) among patients in the emergency medicine department (EMD). METHODS: This is a single-center retrospective chart review conducted over a 10-year period (January 1998 to December 2008). Records with a diagnosis of "dissection of aorta" (International Classification of Diseases, Ninth Revision code 441.0) from the hospital discharge database and hospital death register were selected. Acute aortic dissection was defined as missed if diagnostic imaging to diagnose AAD or cardiothoracic surgeon consult was not elicited while in the EMD. We compared the history, clinical findings, and investigations between patients who had the diagnosis of AAD missed in the EMD and those who did not. RESULTS: A total of 68 patients were included in the analysis during the study period, of which 38.2% had a missed diagnosis. There was 63.2% of type A AAD by Stanford classification. Neither age, sex, nor a history of hypertension were significant risk factors for missed diagnosis of AAD. The likelihood of missed diagnosis was significantly higher in the absence of a pulse deficit (odds ratio, 35.76; 95% confidence interval, 3.70-345.34) and absence of widened mediastinum on chest radiography (odds ratio, 33.16; 95% confidence interval, 5.74-191.49). CONCLUSION: Well-known risk factors for AAD such as age, male sex, and hypertension were not risk factors for missed diagnosis for AAD presenting in the EMD. The absence of pulse deficit or widened mediastinum does not exclude the diagnosis of AAD.

The Effect of COVID-19 Endemicity on the Mental Health of Health Workers.

OBJECTIVES: A major surge in COVID-19 cases despite Singapore's high vaccination has strained the health care system in October 2021. Our aim was to assess and compare Healthcare Worker (HCW) mental well-being in 2021 against a previously published cohort in 2020. DESIGN: Cross-sectional survey study. SETTING AND PARTICIPANTS: HCWs from 4 public hospitals and a primary health care system over a 4-week duration in 2021 coinciding with a major surge compared with a similar period in 2020. METHODS: A survey comprising of the Oldenburg Burnout Inventory (OLBI), Hospital Anxiety and Depression Scale (HADS), and Safety Attitudes Questionnaire (SAQ) was distributed via email. Primary endpoints were the proportion meeting OLBI thresholds for both disengagement and exhaustion and being at risk for both Anxiety and Depression using HADS. Multivariate analysis identified significant predictors among demographic, workplace, and SAQ data. Subgroup analysis of overseas HCWs was performed. RESULTS: We surveyed 1475 HCWs. Significantly more HCWs met primary outcomes using OLBI and HADS than in 2020 (84.1% and 39.6% vs 68.2% and 23.3%, respectively; P < .001). Burnout levels were uniformly high. A HADS score ≥8 in either subscale was significantly associated with meeting burnout thresholds (P < .001). Overseas HCWs (P = .002), South Asian ethnicity (P = .004), preuniversity educational qualifications (P = .026), and longer shift workhours of 8 to <12 (P = .015) and ≥12 (P = .001) were significantly associated with meeting HADS thresholds. Among overseas HCWs (n=407), seeing family more than a year ago was significantly associated with worse OLBI disengagement scores and a greater proportion meeting HADS thresholds vs seeing them within a year or being local HCWs (47.2% vs 37.2% and 35.6%, respectively; P = .001). CONCLUSIONS AND IMPLICATIONS: HCW mental health has objectively worsened between 2020 and 2021 in the pandemic's second year. Avoiding prolonged shifts, adopting preventive mental health strategies, improving patient safety, and attention to HCWs of minority ethnicity, from overseas, and with preuniversity education may help.

Point-of-care bedside gas analyzer: limited use of venous pCO2 in emergency patients.

BACKGROUND: Because arterial punctures are more painful, venous blood gas analysis has been proposed as an alternative. OBJECTIVES: To determine if venous pCO(2) can replace arterial pCO(2) in emergency patients using a bedside blood gas analyzer. METHODS: This is a cross-sectional study. We recruited patients who were deemed by the attending Emergency Physicians to require arterial blood gas analysis to determine their ventilation or acid-base status. A venous and an arterial blood gas sample were drawn from the patient, temporally as close to each other as possible. Both samples were then analyzed using the same bedside blood gas analyzer immediately after collection. RESULTS: There were 122 paired samples obtained. The strength of the association between arterial and venous pCO(2) is r = 0.838 (p = 0.001). The Bland-Altman bias plot methods for agreement show a mean difference of 3.3 mm Hg with two standard deviation limits of agreement being -17.4 to 23.9; 93.4% of the pCO(2) values fell within two standard deviation limits. Venous pCO(2) below 30 mm Hg had a 100% (95% confidence interval [CI] 90.5-100) sensitivity and 100% (95% CI 80.7-100) Negative predictive value to rule out hypercarbia, defined as arterial pCO(2) > 45 mm Hg. CONCLUSIONS: There is significant variability in the arteriovenous difference of pCO(2) readings, hence, arterial punctures are still needed to specifically determine the arterial pCO(2).

Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: A multinational cross-sectional study.

The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

Pandemics and Their Impact on Medical Training: Lessons From Singapore.

The ongoing coronavirus disease 2019 (COVID-19) crisis has hit Singapore hard. As of February 25, 2020, Singapore had the fourth highest number of confirmed COVID-19 infections outside of China, only trailing behind South Korea, Italy, and Japan. This has had reverberating effects on Singapore's health care system, and has, consequently, also affected medical education all the way from the undergraduate to the postgraduate level. While efforts are underway to contain disease spread and transmission, the authors believe that this is an opportune time to examine and reflect on the impact that medical crises like COVID-19 can have on medical training and education and to evaluate "business continuity plans" to ensure quality medical education even in the face of constant disruptions from pandemic outbreaks. Medical training is as important a mandate as patient care and service. The authors believe that even in trying times like this, rich and precious lessons can be sought and taught, which will immensely benefit medical students and residents-the health care leaders of tomorrow. In this Perspective, the authors discuss the various ways in which the COVID-19 crisis has affected medical instruction in Singapore and explore pertinent practical and creative solutions for the continuity of medical training in these trying times, drawing on their previous experience with the Severe Acute Respiratory Syndrome outbreak in 2003 as well as the current ongoing COVID-19 crisis.

Impact of 24-hour specialist coverage and an on-site CT scanner on the timely diagnosis of acute aortic dissection.

INTRODUCTION: Acute aortic dissection (AAD) is a rare and potentially fatal condition that has been known to be missed in diagnoses. Our primary objective was to determine if the availability of 24-hour emergency department (ED) specialist coverage and an on-site computed tomography (CT) scanner reduced the rate of missed diagnoses of AAD. METHODS: We selected records of patients diagnosed with dissection of the aorta from a hospital's discharge database and death register in the period of January 1998 to December 2014. AAD was defined as missed if imaging to diagnose AAD or a cardiology/cardiothoracic surgical consultation was not obtained in the ED. We compared the rates of missed diagnosis before and after the availability of 24-hour ED specialist coverage and an on-site CT scanner in the ED. RESULTS: Among 145 patients, 42 (29.0%) had a missed diagnosis. The proportion of missed AAD was lower in the post-implementation period compared to the pre-implementation period (20.0% vs. 37.3%, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.20‒0.89; p = 0.023). After adjusting for confounders, the difference remained significant (OR 0.31, 95% CI 0.14‒0.70; p = 0.005). In the post-implementation period, concurrent signs of congestive cardiac failure (OR 33.51, 95% CI 1.42‒789.20; p = 0.024) and absence of a widened mediastinum on chest radiography (OR 11.52, 95% CI 1.37‒96.80; p = 0.029) were independent predictors of missed diagnoses. CONCLUSION: The availability of 24-hour ED specialist coverage and an on-site CT scanner improved the diagnosis of AAD in our study.

Cross-sectional study of perceptions of qualities of a good medical teacher among medical students from first to final year.

INTRODUCTION: Defining the characteristics of a good medical teacher has implications for faculty selection and development. Perceptions of characteristics may differ with cultural context and level of training, as medical students progress from didactic preclinical training based on cognitivist learning theory to more complex integration of theory and practice in specific contexts in clinical training based on constructivist learning theory. METHODS: We modified a validated questionnaire with permission from the original authors at Melaka Manipal Medical College, Melaka, Malaysia. Participants rated 35 characteristics on a 5-point Likert scale. The modified questionnaire was validated in a pilot pool of medical students (n = 69), with a Cronbach's alpha of 0.90, and administered to Year 1-5 medical students (n = 917) at the Yong Loo Lin School of Medicine, National University of Singapore, Singapore. RESULTS: Based on the proportion of favourable Likert scoring, four top desirable characteristics were common across Year 1-5 students: good communication skills (84.4%); sound knowledge of subject (82.7%); enthusiasm (78.4%); and providing effective explanations (74.4%). Approachability (p = 0.005), encouraging participation (p < 0.001) and constructive criticism (p < 0.001) were more important to clinical students (Year 3-5) than preclinical students (Year 1-2). CONCLUSION: The top four characteristics were consistent across all years of medical students in this study. Characteristics emphasised in the clinical years facilitate active learner participation, consistent with constructivist learning theory.

Extracellular vesicle Cystatin C and CD14 are associated with both renal dysfunction and heart failure.

AIMS: Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients. METHODS AND RESULTS: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction. CONCLUSIONS: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment.

Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic.

OBJECTIVES: The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs. DESIGN: Cross-sectional survey study. SETTING AND PARTICIPANTS: Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic. METHODS: Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs. RESULTS: Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite. CONCLUSIONS AND IMPLICATIONS: Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.

Mid-regional pro-adrenomedullin outperforms N-terminal pro-B-type natriuretic peptide for the diagnosis of acute heart failure in the presence of atrial fibrillation.

AIMS: The performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in diagnosing acute decompensated heart failure (ADHF) among patients presenting with breathlessness is markedly impaired in the presence of atrial fibrillation (AF). We evaluated the diagnostic performance of mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin T as possible alternative markers for discrimination of ADHF in this setting. METHODS AND RESULTS: Breathless patients (n = 1107) were prospectively and contemporaneously recruited in emergency departments in Singapore and New Zealand. The diagnoses of ADHF and presence of AF were adjudicated by two clinician specialists, blinded to MR-proADM, NT-proBNP and high-sensitivity cardiac troponin T (hs-cTnT) results. MR-proADM exhibited strong discrimination of ADHF with little change in performance irrespective of the presence of AF (area under the curve 0.83 in non-AF vs. 0.76 in AF) compared to NT-proBNP (0.91 vs. 0.71) and hs-cTnT (0.83 vs. 0.62), respectively. The accuracy of MR-proADM (73.3%) for diagnosing ADHF among patients with AF was superior to both NT-proBNP (61.6%) and hs-cTnT (64.6%). The superior performance of MR-proADM remained apparent when data from Singapore and New Zealand were analysed separately. CONCLUSION: In the presence of AF, MR-proADM showed greater discrimination and accuracy, and less impairment in performance compared to that in non-AF cases, for the diagnosis of ADHF, compared to the guideline-endorsed NT-proBNP.

Perceptions of a night float system for intern doctors in an internal medicine program: an Asian perspective.

Long duty hours have been associated with significant medical errors, adverse events, and physician "burn-out". An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors' perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p<0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p<0.001) and reduce physician "burn-out" (95% vs. 5%, p<0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician "burn-out".

Appropriateness of blood culture: A comparison of practices between the emergency department and general wards.

BACKGROUND: The decision to perform a blood culture is influenced by factors, such as the pretest probability of bacteremia, resource availability and individual clinician's preference. The lack of formal guidelines results in inconsistencies in practices and an inappropriate or overuse of blood cultures. The primary aim of this study is to compare the rate of positive blood cultures in the emergency department (ED) and general ward. The secondary aim of this study is to analyze factors associated with a positive blood culture. METHODS: We compared 200 consecutive patients in the ED with 200 consecutive patients with first blood cultures done within 24 h of admission from ED to the general ward. We analyzed the clinical characteristics, proportion of positive blood cultures, and variables associated with a positive blood culture. RESULTS: The percentage of positive blood cultures was 13.5% (n = 27) in the ED group, compared with 6.0% (n = 12) in the general ward group. Contamination rates were higher in the ED compared to general ward (4% vs 0.5%). Heart rate and rigors were independently associated with a positive blood culture in a multivariate logistic regression model. CONCLUSION: There was a lower rate of positive blood cultures in the general ward group. Reasons may include a lower threshold for performing blood cultures in the general ward, and prior antibiotics in the ED reducing the sensitivity of blood cultures taken in the general ward. Adherence to clinical decision rules and education of junior staff are needed to improve the efficiency of blood culture taking practices.

Shortening of median door-to-balloon time in primary percutaneous coronary intervention in Singapore by simple and inexpensive operational measures: clinical practice improvement program.

BACKGROUND: Primary percutaneous coronary intervention is the standard reperfusion strategy for ST-segment elevation myocardial infarction in our center. We aimed to shorten the median door-to-balloon time from over 100 minutes to 90 minutes or less. METHODS: We have been using three strategies since March 2007 to shorten the door-to-balloon time: (1) the intervention team is now activated by emergency department physicians (where previously it had been activated by coronary care unit); (2) all members of the intervention team have converted from using pagers to using cell phones; and (3) as soon as the intervention team is activated, patients are transferred immediately to the cardiac catheterization laboratory (where previously they had waited in the emergency department for the intervention team to arrive). An in-house physician and a nurse would stay with the patients before arrival of the intervention team. RESULTS: During 12 months, 285 nontransfer patients (analyzed, n = 270) underwent primary PCI. The shortest monthly median door-to-balloon time was 59 minutes; the longest monthly median door-to-balloon time was 111 minutes. The overall median door-to-balloon time for the entire 12 months was 72 minutes. On a per-month basis, the median door-to-balloon time was 90 minutes or less in 10 of 12 months. On a per-patient basis, the median door-to-balloon time was 90 minutes or less in 182 patients (67.4%). There was 1 case (0.4%) of inappropriate activation by the emergency department. While waiting for the intervention team to convene, 1 patient (0.4%) deteriorated and had to be resuscitated in the cardiac catheterization laboratory. CONCLUSIONS: Improved health care delivery can be achieved by changing simple and inexpensive operational processes.