N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study.

BACKGROUND: Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE: We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS: Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS: We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS: Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION: ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50417.

Applying Andersen's healthcare utilization model to assess factors influencing patients' expectations for diagnostic tests at emergency department visits during the COVID-19 pandemic.

Background: The uncertainties surrounding the COVID-19 pandemic led to a surge in non-urgent emergency department (ED) attendance among people presenting with upper respiratory tract infection (URTI) symptoms. These non-urgent visits, often manageable in primary care, exacerbated ED overcrowding, which could compromise the quality of ED services. Understanding patients' expectations and the reasons for these ED visits is imperative to mitigate the problem of ED overcrowding. Hence, we assessed the factors influencing patients' expectations for diagnostic tests during their ED visits for uncomplicated URTI during different phases of the pandemic. Methods: We conducted a cross-sectional study on adults with URTI symptoms seeking care at four public EDs in Singapore between March 2021 and March 2022. We segmented the study period into three COVID-19 pandemic phases-containment, transition, and mitigation. The outcome variables are whether patients expected (1) a COVID-19-specific diagnostic test, (2) a non-COVID-19-specific diagnostic test, (3) both COVID-19-specific and non-COVID-19-specific diagnostic tests, or (4) no diagnostic test. We built a multinomial regression model with backward stepwise selection and classified the findings according to Andersen's healthcare utilization model. Results: The mean age of participants was 34.5 (12.7) years. Factors (adjusted odds ratio [95% confidence interval]) influencing expectations for a COVID-19-specific diagnostic test in the ED include younger age {21-40 years: (2.98 [1.04-8.55])}, no prior clinical consultation (2.10 [1.13-3.89]), adherence to employer's health policy (3.70 [1.79-7.67]), perceived non-severity of illness (2.50 [1.39-4.55]), being worried about contracting COVID-19 (2.29 [1.11-4.69]), and during the transition phase of the pandemic (2.29 [1.15-4.56]). Being non-employed influenced the expectation for non-COVID-19-specific diagnostic tests (3.83 [1.26-11.66]). Factors influencing expectations for both COVID-19-specific and non-COVID-19-specific tests include younger age {21-40 years: (3.61 [1.26-10.38]); 41-60 years: (4.49 [1.43-14.13])}, adherence to employer's health policy (2.94 [1.41-6.14]), being worried about contracting COVID-19 (2.95 [1.45- 5.99]), and during the transition (2.03 [1.02-4.06]) and mitigation (2.02 [1.03-3.97]) phases of the pandemic. Conclusion: Patients' expectations for diagnostic tests during ED visits for uncomplicated URTI were dynamic across the COVID-19 pandemic phases. Expectations for COVID-19-specific diagnostic tests for ED visits for uncomplicated URTI were higher among younger individuals and those worried about contracting COVID-19 during the COVID-19 pandemic. Future studies are required to enhance public communications on the availability of diagnostic services in primary care and public education on self-management of emerging infectious diseases such as COVID-19.

A multi-institutional exploration of emergency medicine physicians' attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study.

BACKGROUND: The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians' attitudes and behaviours in four EDs in Singapore. METHODS: We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. RESULTS: We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. CONCLUSIONS: Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Antibiotic expectation, behaviour, and receipt among patients presenting to emergency departments with uncomplicated upper respiratory tract infection during the COVID-19 pandemic.

OBJECTIVES: Pre-COVID-19 pandemic, patients who attended the emergency department (ED) for upper respiratory tract infection (URTI) were more likely to receive antibiotics if they expected them. These expectations could have changed with the change in health-seeking behaviour during the pandemic. We assessed the factors associated with antibiotics expectation and receipt for uncomplicated URTI patients in four Singapore EDs during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study on adult patients with URTI from March 2021 to March 2022 in four Singapore EDs and assessed the determinants of antibiotics expectation and receipt using multivariable logistic regression models. We also assessed the reasons patients expect antibiotics during their ED visit. RESULTS: Among 681 patients, 31.0% expected antibiotics while 8.7% received antibiotics during their ED visit. Factors (adjusted odds ratio [95% confidence interval]) that significantly influenced expectation for antibiotics include: 1) prior consultation for current illness with (6.56 [3.30-13.11]) or without (1.50 [1.01-2.23]) antibiotics prescribed; 2) anticipation for COVID-19 test (1.56 [1.01-2.41]); and 3) poor (2.16 [1.26-3.68]) to moderate (2.26 [1.33-3.84]) knowledge on antibiotics use and resistance. Patients expecting antibiotics were 10.6 times (10.64 [5.34-21.17]) more likely to receive antibiotics. Those with tertiary education were twice (2.20 [1.09-4.43]) as likely to receive antibiotics. CONCLUSION: In conclusion, patients with URTI who expected antibiotics to be prescribed remained more likely to receive it during the COVID-19 pandemic. This highlights the need for more public education on the non-necessity for antibiotics for URTI and COVID-19 to address the problem of antibiotic resistance.

A One-Year Longitudinal Study: Changes in Depression and Anxiety in Frontline Emergency Department Healthcare Workers in the COVID-19 Pandemic.

Frontline healthcare workers (HCWs) fighting COVID-19 have been associated with depression and anxiety, but there is limited data to illustrate these changes over time. We aim to quantify the changes in depression and anxiety amongst Emergency Department (ED) HCWs over one year and examine the factors associated with these changes. In this longitudinal single-centre study in Singapore, all ED HCWs were prospectively recruited face-to-face. Paper-based surveys were administered in June 2020 and June 2021. Depression and anxiety were measured using DASS-21. The results of 241 HCWs who had completed both surveys were matched. There was significant improvement in anxiety amongst all HCWs (Mean: 2020: 2.85 (±3.19) vs. 2021: 2.54 (±3.11); Median: 2020: 2 (0-4) vs. 2021: 2 (0-4), p = 0.045). HCWs living with elderly and with concerns about infection risk had higher odds of anxiety; those living with young children had lower odds of anxiety. There was significant worsening depression amongst doctors (Mean: 2020: 2.71 (±4.18) vs. 2021: 3.60 (±4.50); Median: 2020: 1 (0-3) vs. 2021: 3 (0-5), p = 0.018). HCWs ≥ 41 years, living with elderly and with greater concerns about workload had higher odds of depression. HCWs who perceived better workplace support and better social connectedness had lower odds of depression. In summary, our study showed significant improvement in anxiety amongst ED HCWs and significant worsening depression amongst ED doctors over one year. Age, living with elderly, and concerns about workload and infection risk were associated with higher odds of depression and anxiety.

Singapore Advanced Cardiac Life Support Guidelines 2021.

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

Utility of Spatial Point-Pattern Analysis Using Residential and Workplace Geospatial Information to Localize Potential Outbreak Sources.

Identifying the source of an outbreak facilitates its control. Spatial methods are not optimally used in outbreak investigation, due to a mix of the complexities involved (e.g., methods requiring additional parameter selection), imperfect performance, and lack of confidence in existing options. We simulated 30 mock outbreaks and compared 5 simple methods that do not require parameter selection but could select between mock cases' residential and workplace addresses to localize the source. Each category of site had a unique spatial distribution; residential and workplace address were visually and statistically clustered around the residential neighborhood and city center sites respectively, suggesting that the value of workplace addresses is tied to the location where an outbreak might originate. A modification to centrographic statistics that we propose-the center of minimum geometric distance with address selection-was able to localize the mock outbreak source to within a 500 m radius in almost all instances when using workplace in combination with residential addresses. In the sensitivity analysis, when given sufficient workplace data, the method performed well in various scenarios with only 10 cases. It was also successful when applied to past outbreaks, except for a multisite outbreak from a common food supplier.

Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre.

INTRODUCTION: Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period. METHODS: This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics. RESULTS: Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors. CONCLUSION: TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use.

Outcomes of direct and indirect medical intensive care unit admissions from the emergency department of an acute care hospital: a retrospective cohort study.

OBJECTIVES: This study aimed to determine if the risk of adverse outcomes (in-hospital and 60-day mortality, intensive care unit (ICU) and total hospital length of stay (LOS)) was greater for medical ICU (MICU) or high dependency unit (HDU) patients indirectly admitted from the emergency department (ED) than for directly admitted patients. SETTING: This study was conducted at a large public acute care hospital in Singapore. PARTICIPANTS: In this retrospective cohort study, hospital records of patients who were admitted directly from the ED, or initially admitted to the general wards from the ED and subsequently transferred to the MICU/HDU within 24 h, were reviewed. Patients were included if they were: (A) discharged from the MICU/HDU in 2009 and were admitted from the ED and (B) transferred to the MICU/HDU within 24 h of presentation at the ED. Data from 706 patients were analysed; 58.4% were men with a median age of 61 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The following outcomes were compared: in-hospital mortality, 60-day mortality, LOS at the MICU/HDU, as well as total hospital LOS. RESULTS: Of the 706 patients, 491 (69.5%) were directly admitted to the MICU/HDU. After adjusting for demographics, comorbidities, interventions at the ED and clinical parameters at the ED (heart rate, respiration, oxygen saturation, mean arterial pressure), as well as the Apache II score on arrival at the MICU/HDU, indirectly admitted patients had a higher risk of in-hospital mortality (OR=3.07, 95% CI 1.39 to 6.80), death within 60 days (OR=3.09, 95% CI 1.40 to 6.83) and risk of staying >1 day at the MICU/HDU (OR=2.54, 95% CI 1.48 to 4.36). There was no significant difference in total in-hospital LOS. CONCLUSIONS: Indirectly admitted MICU/HDU patients had generally poorer outcomes. As the magnitude of effect may vary across settings, context-specific studies may be useful for improving outcomes.

Leading and managing an emergency department-A personal view.

The emergency department (ED) is a "unique operation, optimized to exist at the edge of chaos". It is the responsibility of the leaders and managers of the ED to ensure that their teams work in an environment where they can deliver the best care to their patients. This environment is defined by people, system and place. People are the most important asset of the ED. One of the most important responsibilities of the ED leaders and managers (senior management) is to foster teamwork. They will also have to ensure that communication between team members is optimal and that there is a structure in place for conflict resolution. ED senior management should be aware of their team dynamics and know the "movers and shakers" in their organization. ED systems should be kept simple. One of the core businesses of an ED is contingency planning. ED senior management must plan, prepare, practice, review, analyze, assess and strategize for unexpected events. The ED physical environment has an impact on the flow of care being delivered to her patients. ED senior management must manage change. Change works only if it takes root in the hearts and minds of the organization's people. The quality of the leaders and managers of the ED will determine whether or not, their teams work in an environment where they can deliver the best care to their patients.

Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates.

AIM: To determine the efficacy of geriatric assessment and intervention in an emergency department observation unit (EDOU). METHODS: This was a single-centre, before/after prospective study. The control group received the usual EDOU care. Intervention group received geriatric assessment and intervention before discharge. Patients were followed up at 3, 6, 9 and 12 months. End-points included falls and functional scores obtained via telephone, and unscheduled ED re-attendance and hospitalisation obtained through electronic records. RESULTS: The study population included 172 control and 315 intervention group patients. A total of 71.7% of patients in the intervention group had hidden needs that required intervention. The intervention group had significantly less ED re-attendance (adjusted incidence rate ratio (IRR) 0.59, 95% confidence interval (CI) 0.48-0.71) and hospitalisation rates (adjusted IRR 0.64, 95% CI 0.51-0.79) at 12 months. CONCLUSION: Older patients admitted to an EDOU are an at-risk group and benefit from geriatric assessment before discharge.

Predicting hospital admissions at emergency department triage using routine administrative data.

OBJECTIVES: To be able to predict, at the time of triage, whether a need for hospital admission exists for emergency department (ED) patients may constitute useful information that could contribute to systemwide hospital changes designed to improve ED throughput. The objective of this study was to develop and validate a predictive model to assess whether a patient is likely to require inpatient admission at the time of ED triage, using routine hospital administrative data. METHODS: Data collected at the time of triage by nurses from patients who visited the ED in 2007 and 2008 were extracted from hospital administrative databases. Variables included were demographics (age, sex, and ethnic group), ED visit or hospital admission in the preceding 3 months, arrival mode, patient acuity category (PAC) of the ED visit, and coexisting chronic diseases (diabetes, hypertension, and dyslipidemia). Chi-square tests were used to study the association between the selected possible risk factors and the need for hospital admission. Logistic regression was applied to develop the prediction model. Data were split for derivation (60%) and validation (40%). Receiver operating characteristic curves and goodness-of-fit tests were applied to the validation data set to evaluate the model. RESULTS: Of 317,581 ED patient visits, 30.2% resulted in immediate hospital admission. In the developed predictive model, age, PAC status, and arrival mode were most predictive of the need for immediate hospital inpatient admission. The c-statistic of the receiver operating characteristic (ROC) curve was 0.849 (95% confidence interval [CI] = 0.847 to 0.851). The goodness-of-fit test showed that the predicted patients' admission risks fit the patients' actual admission status well. CONCLUSIONS: A model for predicting the risk of immediate hospital admission at triage for all-cause ED patients was developed and validated using routinely collected hospital data. Early prediction of the need for hospital admission at the time of triage may help identify patients deserving of early admission planning and resource allocation and thus potentially reduce ED overcrowding.

Review of studies and guidelines on fasting and procedural sedation at the emergency department.

AIM: Procedural sedation and analgesia allows urgent procedures to be performed safely by preserving patients' airway reflexes. Fasting, which is required before deeper levels of sedation, and where the airway reflexes are not preserved, is difficult to impose in emergencies. This paper aims to synthesise evidence on the need for pre-procedure fasting to minimise aspiration among adults undergoing procedural sedation and analgesia for emergency procedures. METHODS: Overviews, guidelines with graded recommendations and primary studies on aspiration and pre-procedure fasting in procedural sedation and analgesia were retrieved from Medline, Cochrane, and Center for Reviews and Dissemination Databases. Terms searched were procedural sedation, fasting, emergency and sedation. RESULTS: One primary study and one guideline were included. The American College of Emergency Physicians Clinical Policies Subcommittee on Procedural Sedation and Analgesia issued a recommendation based on 'preliminary, inconclusive or conflicting evidence, or on panel consensus'. The recommendation states: 'recent food intake is not a contraindication for administering procedural sedation and analgesia...'. The primary study conducted by Bell in an emergency department in Australia compared patients who last ate or drank more than 6 and 2 h from induction, respectively, with those who last ate or drank within 6 and 2 h. There were no cases of aspiration in both groups. Out of 118 patients who fasted, 1 (0.8%) vomited, as did one of 282 patients (0.4%) who did not fast. CONCLUSIONS: Aspiration risk is expected to be lower in procedural sedation and analgesia than in general anaesthesia. Current guidelines rely on expert consensus due to the lack of primary studies. Contextualisation of existing guidelines are quick and efficient strategies for developing locally relevant tools.

Epidemiology of travel-associated pandemic (H1N1) 2009 infection in 116 patients, Singapore.

In June 2009, during Singapore's pandemic influenza plan containment phase, pandemic (H1N1) 2009 was introduced into the country through imported cases. To understand how travel patterns affected the initial outbreak, we examined epidemiologic and travel data for the first 116 case-patients admitted to Tan Tock Seng Hospital, Singapore, with travel-associated infection. Sixty-one percent and 54% of patients, respectively, met US Centers for Disease Control and Prevention and World Health Organization temperature criteria for influenza-like illness. One fourth of the case-patients traveled after illness onset, and 15% became ill while traveling. Regions of exposure for imported infections changed rapidly; case-patients initially arrived from North America, followed by Australasia and Southeast Asia. Case-patients on longer flights were more likely to become ill before arrival; those with shorter flights tended to become ill after arrival. Thermal scanners detected fevers in 12% of the arriving case-patients, resulting in a shorter time to isolation.

Pandemic (H1N1) 2009 surveillance and prevalence of seasonal influenza, Singapore.

On April 25, 2009, Singapore implemented strict containment measures for pandemic (H1N1) 2009 with enhanced surveillance and hospital isolation. In the first month, seasonal influenza, predominantly virus subtype H3N2, was diagnosed for 32% of patients with acute febrile respiratory illness. Our findings underscore the high prevalence of seasonal influenza in Singapore.

Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department.

AIMS: The aims of our study are to evaluate the use of computed tomographic scan of the head (CT-head) in patients with altered mental status (AMS) presenting to the Emergency Department (ED) and to identify clinical features associated with an abnormal CT-head result. METHODS: In this prospective observational study, we recruited consecutive adult patients with undifferentiated AMS and no major trauma at a busy urban ED over 11 months. Demographical, clinical, radiological and laboratory data were collected prospectively. The primary outcome measure was an abnormal CT-head result. Secondary outcome measures were the distribution of aetiologies of AMS with age, mortality rate and length of hospital stay. Logistic regression was applied to identify variables associated with an abnormal CT-head result. RESULTS: Nine hundred and sixty-seven patients were recruited. The rate of CT-head use in the ED was 41%, with 45% of the scans being abnormal. We identified eight clinical factors associated with an abnormal CT-head result. Odds ratios (95% confidence intervals) for diastolic blood pressure greater than 80 mmHg, focal weakness, Glasgow Coma Score less than 15, antiplatelet use, upgoing plantar response, presence of headache, anticoagulant use and dilated pupils were 1.016 (1.003-1.029), 1.816 (1.063-3.103), 1.899 (1.113-3.242), 2.203 (1.146-4.234), 2.680 (1.623-4.427), 3.369 (1.449-7.830), 3.589 (1.253-10.283) and 5.212 (1.153-23.558), respectively. CONCLUSION: Our study identified important risk factors for an abnormal CT-head result which can be used in future research to establish a guideline for rational ordering of the test in AMS patients.