Development of prehospital emergency care in Singapore.

This review paper describes the development of the pre-hospital system in Singapore from the pre-war days. Every country's prehospital community needs a deep understanding of how they developed over the years, factors that played a part, and the aspirations their community and government have set for this. This can guide future evolution of the services to ensure that care provided is relevant, applicable and in keeping with the community's needs. Countries with similar contextual circumstances, but at a different stage of development of their PECs, may learn from these.

Characteristics of injuries resulting from falls from height in the construction industry

INTRODUCTION@#Falls from heights contribute to 34% of fatal accidents in Singapore. Of these, 51% of the accidents occur in the construction industry. This retrospective review, of all persons falling from heights in the construction industry from 2006 to 2012 and attending a major hospital, analysed injury patterns and related them to mechanisms and contributory factors.@*METHODS@#Information collected included injury and casualty characteristics, safety measures, pre-existing medical conditions and clinical outcomes.@*RESULTS@#Of 1,085 patients, 951 were male with a mean age of 39.8 years, mean height of 165.9 cm and mean weight of 69.7 kg. Most of the casualties fell between 0800 and 2000 hours. Among the severely injured patients, 2.4% had head injuries, 54.9% had chest injuries and 39.2% had abdominal and pelvic injuries. For these casualties, the mortality rate was 60.8%. For patients with less than major trauma, the commonest injuries were in the lower limbs (41.8%), upper limbs (40.8%) and spine (22.2%). All the casualties survived. Falls from scaffolding, formwork and platforms were the most common causes of severe injuries (41.1%). Safety helmets and harnesses were reported to be used in 1.8% and 4.1% of instances of falls, respectively.@*CONCLUSION@#Studying the patterns of injuries following falls at construction sites has the potential for injury prevention through safe practices, use of safety equipment and targeted training.

Characteristics of unplanned hospitalisations among cancer patients in Singapore.

INTRODUCTION: Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable. METHODS: Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions. RESULTS: Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED. CONCLUSION: Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.

Development of a Medical Support Training Program for Disaster Management in Indonesia: A Hospital Disaster Medical Support Program for Indonesia.

Disasters are often unforeseen events. Hospitals form a critical component of any country's disaster management medical support system. To ensure optimal operations, minimize chaos, and allow flexibility in response, planning and practice are crucial. Singapore Health Services (SingHealth) collaborated with Hasanuddin University (UnHas) in Makassar, Indonesia, to develop a Hospital Disaster Medical Support (HDMS) program for the province of South Sulawesi, Indonesia. An assessment of the needs of the hospitals in Makassar, Indonesia, for disaster preparedness was carried out. A curriculum for the HDMS program was developed based on the assessment. Discussions with stakeholders of various hospitals were held for the implementation of this program. A total of 310 participants were trained in this program over the two-year period. The feedback from the participants was positive. The exercises provided a more realistic simulation of the concepts of hospital management in a disaster situation. Up to 73 persons were also trained as program instructors during this period. The development of the cadre of instructors in hospital disaster medical support will likely help sustain the program for the next few years.

Reorganising the emergency department to manage the COVID-19 outbreak.

BACKGROUND: The COVID-19 disease outbreak that first surfaced in Wuhan, China, in December 2019, has taken the world by storm and ravaged almost every country in the world. Emergency departments (ED) in hospitals are on the frontlines, serving an essential function in identifying these patients, isolating them early whilst providing urgent medical care. This outbreak has reinforced the role of Emergency Medicine in public health. This paper documents the challenges faced and measures taken by a tertiary hospital's ED in Singapore, in response to the outbreak. MAIN BODY: The ED detected the first case of COVID-19 in Singapore on 22 January 2020 in a Chinese tourist and also the first case of locally transmitted COVID-19 on 3 February 2020. The patient journeys through the patient reception area in the ED and undergoes fever screening before being shunted to isolation areas within the ED. Management and disposition of suspect COVID-19 patients are guided by a close-knit collaboration between ED and department of infectious diseases. With increasing number of patients, back-up plans for expansion of space and staff augmentation have been enacted. Staff safety is also of utmost importance, with provision and guidelines for personal protective equipment and team segregation to ensure no cross-contamination across staff. These have been made possible with an early setup of an operational command and control structure within the ED, managing manpower, logistics, operations, communication and information management and liaison with other clinical departments. CONCLUSION: With the large numbers of undifferentiated patients managed by the ED to date, more than 820 patients with COVID-19 have been identified in the hospital. Not a single member of the staff of the SGH Emergency Department has come down with the illness. The various measures undertaken by the department have helped to ensure good staff morale and strict adherence to safety procedures. We share the lessons learnt so that others who manage EDs around the world can benefit from our experience.

Advanced Cardiac Life Support: 2016 Singapore Guidelines

The main areas of emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are: early recognition of cardiac arrest and call for help; good-quality chest compressions; early defibrillation when applicable; early administration of drugs; appropriate airway management ensuring normoventilation; and delivery of appropriate post-resuscitation care to enhance survival. Of note, it is important to monitor the quality of the various care procedures. The resuscitation team needs to reduce unnecessary interruptions to chest compressions in order to maintain adequate coronary perfusion pressure during the ACLS drill. In addition, the team needs to continually look out for reversible causes of the cardiac arrest.

Singapore Defibrillation Guidelines 2016

The most common initial rhythm in a sudden cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. This is potentially treatable with defibrillation, especially if provided early. However, any delay in defibrillation will result in a decline in survival. Defibrillation requires coordination with the cardiopulmonary resuscitation component for effective resuscitation. These two components, which form the key links in the chain of survival, have to be brought to the cardiac victim in a timely fashion. An effective chain of survival is needed in both the institution and community settings.

Role of peak current in conversion of patients with ventricular fibrillation

<p><b>INTRODUCTION</b>Peak currents are the final arbiter of defibrillation in patients with ventricular fibrillation (VF). However, biphasic defibrillators continue to use energy in joules for electrical conversion in hopes that their impedance compensation properties will address transthoracic impedance (TTI), which must be overcome when a fixed amount of energy is delivered. However, optimal peak currents for conversion of VF remain unclear. We aimed to determine the role of peak current and optimal peak levels for conversion in collapsed VF patients.</p><p><b>METHODS</b>Adult, non-pregnant patients presenting with non-traumatic VF were included in the study. All defibrillations that occurred were included. Impedance values during defibrillation were used to calculate peak current values. The endpoint was return of spontaneous circulation (ROSC).</p><p><b>RESULTS</b>Of the 197 patients analysed, 105 had ROSC. Characteristics of patients with and without ROSC were comparable. Short duration of collapse < 10 minutes correlated positively with ROSC. Generally, patients with average or high TTI converted at lower peak currents. 25% of patients with high TTI converted at 13.3 ± 2.3 A, 22.7% with average TTI at 18.2 ± 2.5 A and 18.6% with low TTI at 27.0 ± 4.7 A (p = 0.729). Highest peak current conversions were at < 15 A and 15-20 A. Of the 44 patients who achieved first-shock ROSC, 33 (75.0%) received < 20 A peak current vs. > 20 A for the remaining 11 (25%) patients (p = 0.002).</p><p><b>CONCLUSION</b>For best effect, priming biphasic defibrillators to deliver specific peak currents should be considered.</p>

The National Resuscitation Council, Singapore, and 34 years of resuscitation training: 1983 to 2017

Training in the modern form of cardiopulmonary resuscitation (CPR) started in Singapore in 1983. For the first 15 years, the expansion of training programmes was mainly owing to the interest of a few individuals. Public training in the skill was minimal. In an area of medical care where the greatest opportunity for benefit lies in employing core resuscitation skills in the prehospital environment, very little was being done to address such a need. In 1998, a group of physicians, working together with the Ministry of Health, set up the National Resuscitation Council (NRC). Over the years, the NRC has created national guidelines on resuscitation and reviewed them at five-yearly intervals. Provider training manuals are now available for most programmes. The NRC has set up an active accreditation system for monitoring and maintaining standards of life support training. This has led to a large increase in the number of training centres, as well as recognition and adoption of the council's guidelines in the country. The NRC has also actively promoted the use of bystander CPR through community-based programmes, resulting in a rise in the number of certified providers. Improving the chain of survival, through active community-based training programmes, will likely lead to more lives being saved from sudden cardiac arrest.

Prompt use of mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the MECCA study report

<p><b>INTRODUCTION</b>Early use of mechanical cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) may improve survival outcomes. Current evidence for such devices uses outcomes from an intention-to-treat (ITT) perspective. We aimed to determine whether early use of mechanical CPR using a LUCAS 2 device results in better outcomes.</p><p><b>METHODS</b>A prospective, randomised, multicentre study was conducted over one year with LUCAS 2 devices in 14 ambulances and manual CPR in 32 ambulances to manage OHCA. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were survival at 24 hours, discharge from hospital and 30 days.</p><p><b>RESULTS</b>Of the 1,274 patients recruited, 1,191 were eligible for analysis. 889 had manual CPR and 302 had LUCAS CPR. From an ITT perspective, outcomes for manual and LUCAS CPR were: ROSC 29.2% and 31.1% (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82-1.45; p = 0.537); 24-hour survival 11.2% and 13.2% (OR 1.20, 95% CI 0.81-1.78; p = 0.352); survival to discharge 3.6% and 4.3% (OR 1.20, 95% CI 0.62-2.33; p = 0.579); and 30-day survival 3.0% and 4.0% (OR 1.32, 95% CI 0.66-2.64; p = 0.430), respectively. By as-treated analysis, outcomes for manual, early LUCAS and late LUCAS CPR were: ROSC 28.0%, 36.9% and 24.5%; 24-hour survival 10.6%, 15.5% and 8.2%; survival to discharge 2.9%, 5.8% and 2.0%; and 30-day survival 2.4%, 5.8% and 0.0%, respectively. Adjusted OR for survival with early LUCAS vs. manual CPR was 1.47 after adjustment for other variables (p = 0.026).</p><p><b>CONCLUSION</b>This study showed a survival benefit with LUCAS CPR as compared to manual CPR only, when the device was applied early on-site.</p>

The golden hours in paediatric septic shock--current updates and recommendations.

INTRODUCTION: Paediatric sepsis is a global health problem. It is the leading cause of mortality in infants and children worldwide. Appropriate and timely initial management in the first hours, often termed as the "golden hours", has great impact on survival. The aim of this paper is to summarise the current literature and updates on the initial management of paediatric sepsis. MATERIALS AND METHODS: A comprehensive literature search was performed via PubMed using the search terms: 'sepsis', 'septic shock', 'paediatric' and 'early goal-directed therapy'. Original and review articles were identified and selected based on relevance to this review. RESULTS: Early recognition, prompt fluid resuscitation and timely administration of antibiotics remain key in the resuscitation of the septic child. Use of steroids and tight glycaemic control in this setting remain controversial. CONCLUSION: The use of early goal-directed therapy has had significant impact on patient outcomes and protocolised resuscitation of children in septic shock is recommended.

National inventory of emergency departments in Singapore.

BACKGROUND: Emergency departments (EDs) are the basic units of emergency care. We performed a national inventory of all Singapore EDs and describe their characteristics and capabilities. METHODS: Singapore EDs accessible to the general public 24/7 were surveyed using the National ED Inventories instrument ( http://www.emnet-nedi.org). ED staff members were asked about ED characteristics with reference to calendar year 2007. RESULTS: Fourteen EDs participated (100% response). All EDs were located in hospitals, and most (92%) were independent departments. One was a psychiatric ED; the rest were general EDs. Among general EDs, all had a contiguous layout, with medical and surgical care provided in one area. All but two EDs saw both adults and children; one ED was adult-only, and the other saw only children. Six were in the public sector and seven in private health-care institutions, with public EDs seeing the majority (78%) of ED patients. Each private ED had an annual patient census of <30,000. These EDs received 2% of ambulances and had an inpatient admission rate of 7%. Each public ED had an annual census of >60,000. They received 98% of ambulances and had an inpatient admission rate of 30%. Two public EDs reported being overcapacity; no private EDs did. For both public and private EDs, availability of consultant resources in EDs was high, while technological resources varied. CONCLUSION: Characteristics and capabilities of Singapore EDs varied and were largely dependent on whether they are in public or private hospitals. This initial inventory establishes a benchmark to further monitor the development of emergency care in Singapore.

Improving door-to-balloon times in primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: the value of an audit-driven quality initiative

<p><b>INTRODUCTION</b>The study was designed to reduce door-to-balloon times in primary percutaneous coronary intervention for patients presenting to the Emergency Department with acute ST-elevation myocardial infarction, using an audit as a quality initiative.</p><p><b>MATERIALS AND METHODS</b>A multidisciplinary work group performed a pilot study over 3 months, then implemented various process and work-flow strategies to improve overall door-to-balloon times.</p><p><b>RESULTS AND CONCLUSION</b>We developed a guideline-based, institution-specific written protocol for triaging and managing patients who present to the Emergency Department with symptoms suggestive of STEMI, resulting in shortened median door-to-balloon times from 130.5 to 109.5 minutes (P<0.001).</p>

Comparison of termination-of-resuscitation guidelines for out-of-hospital cardiac arrest in Singapore EMS.

CONTEXT: Termination of resuscitation (TOR) in the field for out-of-hospital cardiac arrest (OHCA) can reduce unnecessary transport to hospital and increase availability of resources for other patients. OBJECTIVES: To compare the performance of three TOR guidelines for Basic Life Support-Defibrillator (BLS-D) providers when applied to cardiac arrest patients in the Cardiac Arrest and Resuscitation Epidemiology (CARE) study. DESIGN: This prospective cohort study involved all OHCA patients attended by BLS-D providers in a large urban center. The data analyses were conducted secondarily on these prospectively collected data. Three TOR guidelines proposed by Marsden et al. [BMJ 1995;311:49-51], Petrie [CJEM 2001;3:186-92] and Verbeek et al. [Acad Emerg Med 2002;9:671-8] were applied to show the relationship between the guidelines and actual survival. RESULTS: From 1 October 2001 to 14 October 2004, 2269 patients were enrolled into the study. Thirty-two (1.4%) survived to hospital discharge. For the 3 TOR guidelines, sensitivity was 93.8% (95%CI=79.9-98.3) (Petrie), 81.3% (95%CI=64.7-91.1) (Verbeek) and 90.6% (95%CI=75.8-96.8) (Marsden). Negative predictive value was 99.7% (95%CI=99.0-100.0) (Petrie), 99.6% (95%CI=99.2-99.8) (Verbeek) and 99.8% (95%CI=99.4-99.9) (Marsden). Application of these guidelines would have resulted in transport of 68.4% (Petrie), 31.3% (Verbeek) and 36.1% (Marsden) of cases. The Petrie guidelines would have recommended TOR in two patients who eventually survived. Similarly TOR was recommended in six patients for Verbeek and three patients for Marsden who eventually survived. CONCLUSION: We found all three TOR guidelines to have high sensitivity and negative predictive value. However the specificity and transport rates varied greatly. Application of any TOR guidelines may be affected by local EMS and population factors which should be considered in any policy decision.

Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: The benefit of epinephrine in cardiac arrest is controversial and has not been conclusively shown in any human clinical study. We seek to assess the effect of introducing intravenous epinephrine on the survival outcomes of out-of-hospital cardiac arrest patients in an emergency medical services (EMS) system that previously did not use intravenous medications. METHODS: This observational, prospective, before-after clinical study constitutes phase II of the Cardiac Arrest and Resuscitation Epidemiology project. Included were all patients who are older than 8 years, with nontraumatic out-of-hospital cardiac arrest conveyed by the national emergency ambulance service. The comparison between the 2 intervention groups for survival to discharge was made with logistic regression and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI). RESULTS: From October 1, 2002, to October 14, 2004, 1,296 patients were enrolled into the study, with 615 in the pre-epinephrine and 681 in the epinephrine phase. Demographic and EMS characteristics were similar in both groups. Forty-four percent of patients received intravenous epinephrine in the epinephrine phase. There was no significant difference in survival to discharge (pre-epinephrine 1.0%; epinephrine 1.6%; OR 1.7 [95% CI 0.6 to 4.5]; adjusted for rhythm OR 2.0 [95% CI 0.7 to 5.5]); return of circulation (pre-epinephrine 17.9%; epinephrine 15.7%; OR 0.9 [95% CI 0.6 to 1.2]), or survival to admission (pre-epinephrine 7.5%; epinephrine 7.5%; OR 1.0 [95% CI 0.7 to 1.5]). There was a minimal increase in scene time in the epinephrine phase (10.3 minutes versus 10.7 minutes; 95% CI of difference 0.02 to 0.94 minutes). CONCLUSION: We were unable to establish a significant survival benefit with the introduction of intravenous epinephrine to an EMS system. More research is needed to determine the effectiveness of drugs such as epinephrine in resuscitation.

Out-of-hospital cardiac arrests occurring in primary health care facilities in Singapore.

OBJECTIVES: To study out-of-hospital cardiac arrests (OHCA) occurring in primary healthcare facilities (HCF) in Singapore and to compare these with arrests occurring in the community. METHODS: This prospective observational study was part of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with OHCA occurring in HCF. Patient characteristics, cardiac arrest circumstances, EMS response and outcomes were recorded according to the Utstein style. RESULTS: From 1 October 2001 to 14 October 2004, the data from 2428 subjects were received of which 138 patients were OHCA occurring in HCF. This is an incidence of 1.12/100,000 population per year and constituted 6.0% of all OHCA. Arrest occurring in HCF were more likely to be witnessed (p<0.01), or have bystander CPR (p<0.01). The HCF group was also more likely to receive CPR with both compression and ventilation (p<0.01) and have a non-trauma cause of arrest (p=0.03). HCF arrests also had a shorter collapse to call (EMS number) than the non-HCF group (HCF 1.54min versus non-HCF 5.36min, p=0.01). However, no HCF patient received defibrillation prior to EMS arrival. HCF patients were more likely to have return of spontaneous circulation at any time (p=0.05), survival to hospital admission (p<0.01) and survival to discharge (p<0.01) compared to non-HCF patients. CONCLUSION: This study suggests that primary health care providers do have an important role locally in managing out-of-hospital cardiac arrest. We propose an initiative to encourage early defibrillation by primary health care providers.