Characteristics of migrant workers admitted from the emergency department.

INTRODUCTION: Emergency department (ED) admissions for non-work-related injuries and illnesses in the migrant worker (MW) population in Singapore are not well studied. We aimed to examine ED triage acuity and bills associated with admissions among MW for non-trauma, workplace injury (WI) trauma, and non-workplace injury (NWI) trauma. METHODS: In this retrospective observational study, we included all work permit holders admitted to hospital via the ED of three public hospitals from 1 May 2016 to 31 October 2016. Data obtained from medical records included demographics, triage acuity and bill information. RESULTS: There were 1,750 unique patients accounting for 1,788 admissions. The median age was 33 (interquartile range 27-40) years, with a male predominance of 67%. Trauma accounted for 33% ( n = 595) of admissions, and of these, 73% ( n = 433) were due to WI. Admissions for NWI, as compared to WI, were more likely to present as high acuity P1 cases (43% vs 24%, P < 0.001), be conveyed by ambulance (49% vs 24%, P < 0.001) and result in trauma team activations (29% vs 7%, P < 0.001). More NWI admissions (22%, 36/162) exceeded the insurance claim limit under prevailing healthcare policies, as compared to WI admissions (3%, 13/433). CONCLUSION: Migrant workers are admitted to hospital for non-trauma conditions more frequently than for trauma. Non-workplace injury trauma may be severe. Non-trauma and NWI admissions can result in large bills that exceed mandatory insurance coverage. Recent changes to healthcare policy governing MW to allow copayment of large bills and better access to primary care are timely.

Randomised Controlled Trial Assessing Head Down Deep Breathing Method Versus Modified Valsalva Manoeuvre for Treatment of Supraventricular Tachycardia in the Emergency Department.

INTRODUCTION: Supraventricular tachycardia (SVT) is commonly encountered in the emergency department (ED). Vagal manoeuvres are internationally recommended therapy in stable patients. The head down deep breathing (HDDB) technique was previously described as an acceptable vagal manoeuvre, but there are no studies comparing its efficacy to other vagal manoeuvres. Our objective in this study was to compare the rates of successful cardioversion with HDDB and the commonly practiced, modified Valsalva manoeuvre (VM). METHODS: We conducted a randomised controlled trial at an acute hospital ED. Patients presenting with SVT were randomly assigned to HDDB or modified VM in a 1:1 ratio. A block randomisation sequence was prepared by an independent biostatistician, and then serially numbered, opaque, sealed envelopes were opened just before the intervention. Patients and caregivers were not blinded. Primary outcome was cardioversion to sinus rhythm. Secondary outcome(s) included adverse effects/complications of each technique. RESULTS: A total of 41 patients were randomised between 1 August, 2018-1 February, 2020 (20 HDDB and 21 modified VM). Amongst the 41 patients, three spontaneously cardioverted to sinus rhythm before receiving the allocated treatment and were excluded. Cardioversion was achieved in six patients (31.6%) and seven patients (36.8%) with HDDB and modified VM, respectively (odds ratio 1.26, 95% confidence interval, 0.33, 4.84, P = 0.733). Seventeen (89.5%) patients in the HDDB group and 14 (73.7%) from the modified VM group did not encounter any adverse effects. No major adverse cardiovascular events were recorded. CONCLUSION: Both the head down deep breathing technique and the modified Valsalva manoeuvre appear safe and effective in cardioverting patients with SVT in the ED.

Head Down Deep Breathing for Cardioversion of Paroxysmal Supraventricular Tachycardia.

The first-line recommended treatment for stable paroxysmal supraventricular tachycardia (PSVT) is the use of vagal maneuvers. Often the Valsalva maneuver is conducted. We describe two patients who converted to sinus rhythm without complications, using a head down deep breathing (HDDB) technique.

Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission.

STUDY OBJECTIVE: Reducing door-to-balloon times for acute ST-segment elevation myocardial infarction (STEMI) patients has been shown to improve long-term survival. We aim to reduce door-to-balloon time for STEMI patients requiring primary percutaneous coronary intervention by adoption of out-of-hospital 12-lead ECG transmission by Singapore's national ambulance service. METHODS: This was a nationwide, before-after study of STEMI patients who presented to the emergency departments (ED) and required percutaneous coronary intervention. In the before phase, chest pain patients received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were performed by ambulance crews and transmitted from the field to the ED. Patients whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2 or more contiguous leads and symptom onset of less than 12 hours' duration were eligible for percutaneous coronary intervention activation before arrival. RESULTS: ECGs (2,653) were transmitted by the ambulance service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from the before and 156 from the after phase met inclusion criteria for analysis. Median door-to-balloon time was 75 minutes in the before and 51 minutes in the after phase (median difference=23 minutes; 95% confidence interval 18 to 27 minutes). Median door-to-balloon times were significantly reduced regardless of presentation hours. Overall, there was significant reduction in door-to-activation, door-to-ECG, and door-to-cardiovascular laboratory times. No significant difference was found pertaining to adverse events. CONCLUSION: This study describes a nationwide implementation of out-of-hospital ECG transmission resulting in reduced door-to-balloon times, regardless of presentation hours. Out-of-hospital ECG transmission should be adopted as best practice for management of chest pain.

Outpatient treatment of primary spontaneous pneumothorax using a small-bore chest drain with a Heimlich valve: the experience of a Singapore emergency department.

AIM: To review the outcomes and safety profile of small-bore (8 Fr) chest drains with a Heimlich valve for the treatment of primary spontaneous pneumothorax. METHODOLOGY: A retrospective casenotes review was carried out for pneumothorax cases treated with a small-bore chest drain and connected to a Heimlich valve in the emergency department during a 14-month period from 1 August 2009 to 30 September 2010. Inclusion criteria were primary spontaneous pneumothorax, first episode, unilateral, at least 2-cm rim of air and no or minimal associated pleural effusion. Exclusion criterion was tension pneumothorax. Key outcomes studied were the success rate, as defined by sustained, complete lung re-expansion without the need for alternative intervention (e.g. conventional chest tube or surgery) or admission and complication rates. RESULTS: A total of 55 patients fulfilled the inclusion criteria and were treated with an 8 Fr chest tube and a Heimlich valve. The study population was predominantly (87.3%) male. The age range was 14-48 years (median 20). The overall success rate (as defined above) was 65.5% [95% confidence interval (CI): 51.4-77.8%]. The rate of surgical pleurodesis was 23.6% (95% CI: 13.2-37%). Complications encountered were tube blockage by haemoserous discharge (1.8%; 95% CI: 0-9.7%) and tube dislodgement (5.5%; 95% CI: 1.1-15.1%). CONCLUSION: Our results suggest that the use of a small-bore chest drain and a Heimlich valve is a safe and efficacious mode of treatment for primary spontaneous pneumothorax, which enables management of the majority of these patients as outpatients.