Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol.

BACKGROUND: The challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy-in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions. METHODS: Employing a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores. DISCUSSION: Confronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT's efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model's prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04447079. Initiated on 25 June 2020.

Outcome assessment for out-of-hospital cardiac arrest patients in Singapore and Japan with initial shockable rhythm.

BACKGROUND: Singapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models. METHODS: This was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18-74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012-2017, validation data 2018-2019), and applied to the SG-PAROS database (2010-2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed-expected ratio (OE ratio) with 95% confidence intervals (CI). RESULTS: From the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784-1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258-0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065-0.235]). CONCLUSION: This observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.

Comparing outcomes of out-of-hospital cardiac arrest patients with initial shockable rhythm in Singapore and Osaka using population-based databases.

BACKGROUND: Previous research indicated outcomes among refractory out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm were different in Singapore and Osaka, Japan, possibly due to the differences in access to extracorporeal cardiopulmonary resuscitation. However, this previous study had a risk of selection bias. To address this concern, this study aimed to evaluate the outcomes between Singapore and Osaka for OHCA patients with initial shockable rhythm using only population-based databases. METHODS: This was a secondary analysis of two OHCA population-based databases in Osaka and Singapore, including adult OHCA patients with initial shockable rhythm. A machine-learning-based prediction model was derived from the Osaka data (n = 3088) and applied to the PAROS-SG data (n = 2905). We calculated the observed-expected ratio (OE ratio) for good neurological outcomes observed in Singapore and the expected derived from the data in Osaka by dividing subgroups with or without prehospital ROSC. RESULTS: The one-month good neurological outcomes in Osaka and Singapore among patients with prehospital ROSC were 70% (791/1,125) and 57% (440/773), and among patients without prehospital ROSC were 10% (196/1963) and 2.8% (60/2,132). After adjusting patient characteristics, the outcome in Singapore was slightly better than expected from Osaka in patients with ROSC (OE ratio, 1.067 [95%CI 1.012 to 1.125]), conversely, it was worse than expected in patients without prehospital ROSC (OE ratio, 0.238 [95%CI 0.173 to 0.294]). CONCLUSION: This study showed the outcomes of OHCA patients without prehospital ROSC in Singapore were worse than expected derived from Osaka data even using population-based databases. (249/250 words).

Improved Out-of-Hospital Cardiac Arrest Survival with a Comprehensive Dispatcher-Assisted CPR Program in a Developing Emergency Care System.

OBJECTIVE: Out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Studies have demonstrated improved survival with early bystander cardiopulmonary resuscitation (BCPR). This study evaluated the impact of a dispatcher-assisted CPR (DA-CPR) program on BCPR rate and outcomes of OHCA in a developing emergency medical services (EMS) system setting. METHODS: Data were extracted from the national cardiac arrest registry. A before-after analysis was performed between OHCA cases with cardiac etiology conveyed by EMS from April 2010-June 2012 (pre-intervention) and July 2012-December 2015 (post-intervention). Primary outcomes were survival-to-discharge/30 days post-arrest and favorable cerebral performance (Glasgow-Pittsburgh cerebral performance categories 1 and 2). RESULTS: 6365 OHCA cases were analyzed with 2129 in the pre-intervention and 4236 in the post-intervention group. In the post-intervention group, there was an increase in BCPR rates from 24.8% to 53.8% (p < 0.001), adjusted OR 3.67 (aOR; 95%CI: 3.26-4.13). OHCA outcomes also improved with survival-to-discharge rates increasing from 3.0%-4.5% (p < 0.01), aOR 2.10 (95%CI: 1.40-3.17) and favorable cerebral performance increasing from 1.6% to 2.7% (p < 0.05), aOR 2.82 (95%CI: 1.65-4.82). In patients with initial shockable rhythm, BCPR without dispatcher assistance was associated with significantly higher odds of survival-to-discharge (aOR 1.67, 95%CI: 1.06-2.64) and favorable cerebral performance (aOR 2.32, 95%CI: 1.26-4.27) compared to no BCPR. CONCLUSION: Our study showed that a simplified DA-CPR program can be successfully implemented in a developing EMS system and can contribute to higher BCPR rate and in turn, improve OHCA survival. Future studies can examine bystanders' characteristics and quality of the CPR performed to understand their impact on survival.

Emergency medical dispatch services across Pan-Asian countries: a web-based survey.

BACKGROUND: Dispatch services (DS's) form an integral part of emergency medical service (EMS) systems. The role of a dispatcher has also evolved into a crucial link in patient care delivery, particularly in dispatcher assisted cardio-pulmonary resuscitation (DACPR) during out-of-hospital cardiac arrest (OHCA). Yet, there has been a paucity of research into the emerging area of dispatch science in Asia. This paper compares the characteristics of DS's, and state of implementation of DACPR within the Pan-Asian Resuscitation Outcomes (PAROS) network. METHODS: A cross-sectional descriptive survey addressing population characteristics, DS structures and levels of service, state of DACPR implementation (including protocols and quality improvement programs) among PAROS DS's. RESULTS: 9 DS's responded, representing a total of 23 dispatch centres from 9 countries that serve over 80 million people. Most PAROS DS's operate a tiered dispatch response, have implemented medical oversight, and tend to be staffed by dispatchers with a predominantly medical background. Almost all PAROS DS's have begun tracking key EMS indicators. 77.8% (n = 7) of PAROS DS's have introduced DACPR. Of the DS's that have rolled out DACPR, 71.4% (n = 5) provided instructions in over one language. All DS's that implemented DACPR and provided feedback to dispatchers offered feedback on missed OHCA recognition. The majority of DS's (83.3%; n = 5) that offered DACPR and provided feedback to dispatchers also implemented corrective feedback, while 66.7% (n = 4) offered positive feedback. Compression-only CPR was the standard instruction for PAROS DS's. OHCA recognition sensitivity varied widely in PAROS DS's, ranging from 32.6% (95% CI: 29.9-35.5%) to 79.2% (95% CI: 72.9-84.4%). Median time to first compression ranged from 120 s to 220 s. CONCLUSIONS: We found notable variations in characteristics and state of DACPR implementation between PAROS DS's. These findings will lay the groundwork for future DS and DACPR studies in the PAROS network.

Comparison of Outcomes and Characteristics of Emergency Medical Services (EMS)-Witnessed, Bystander-Witnessed, and Unwitnessed Out-of-Hospital Cardiac Arrests in Singapore.

Objectives: The objective was to compare the survival outcomes of emergency medical services (EMS)-witnessed to bystander-witnessed, and unwitnessed out-of-hospital cardiac arrests (OHCA) in Singapore. Secondary aims are to describe the 5-year trend in survival rates of EMS-witnessed arrests. Methods: This was a retrospective analysis of the Singapore's OHCA registry data from 2011 to 2015. Excluded from the analysis were patients younger than 18 years old, arrests of traumatic etiology, resuscitation not attempted, and cases not conveyed by EMS. The primary outcome was survival to hospital discharge or 30 days post-arrest. Secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Results: 8,394 cases were analyzed, with 650 (7.7%) EMS-witnessed arrests, 4480 (53.4%) bystander-witnessed arrests, and 3264 (38.9%) unwitnessed arrests. Among EMS-witnessed arrests, the majority were presumed to be of cardiac etiology (62.8%) and the most common presenting rhythm was pulseless electrical activity (PEA; 57.2%). Survival to discharge or 30th day post-arrest was higher in EMS-witnessed arrests compared to bystander-witnessed and unwitnessed arrests (11.2% vs. 5.3% and 1.3%, p < 0.001). Survival to discharge for EMS-witnessed cases increased from 2011 (13.2%) to 2015 (18.9%). Conclusions: EMS-witnessed OHCAs were more likely to have favorable outcomes compared to bystander-witnessed and unwitnessed OHCAs. High PEA rates in EMS-witnessed arrests were associated with older patients with underlying preexisting medical conditions. Increasing public awareness on recognition of prodromal symptoms and early activation of EMS could improve post-arrest survival and neurological outcomes of OHCA.

Ethnic and Neighborhood Socioeconomic Differences In Incidence and Survival From Out-Of-Hospital Cardiac Arrest In Singapore.

Objective: We aimed to examine the association of ethnicity and socioeconomic status (SES) with Out-of-Hospital Cardiac Arrest (OHCA) incidence and 30-day survival in Singapore. Methods: We analyzed the Singapore cohort of Pan-Asia Resuscitation Outcome Study (PAROS), a multi-center, prospective OHCA registry between 2010 and 2015. The Singapore Socioeconomic Disadvantage Index (SEDI) score, obtained according to zip code, was used as surrogate for neighborhood SES. Age-adjusted OHCA incidence and Utstein survival were calculated by ethnicity and SES. Utstein survival was defined as the number of cardiac OHCA cases with initial rhythm of ventricular fibrillation witnessed by a bystander who survived 30-days or until hospital discharge. Logistic regression was used to investigate association of ethnicity with 30-day and Utstein survivals. Results: Our study population comprised 8,900 patients: 6,453 Chinese, 1,472 Malays, and 975 Indians. The overall age-adjusted incidence ratios (95% CI) for Malay/Chinese and Indian/Chinese were 1.93 (1.83-2.04) and 1.95 (1.83-2.08), respectively. The overall age-adjusted incidence ratios (95% CI) for average/low and high/low SEDI group were 1.12 (0.95-1.33) and 1.29 (1.08-1.53), respectively. Malay showed lesser Utstein survival of 8.1% compared to Chinese (14.6%) and Indian (20.4%) [p = 0.018]. Ethnicity did not reach statistical significance (p = 0.072) in forward selection model of Utstein survival, while SEDI score and category were not significant (p > 0.2 and p = 0.349). Conclusions: We found Malay and Indian communities to be at higher risks of OHCA compared to Chinese, and additionally, the Malay community is at higher risk of subsequent mortality than the Chinese and Indian communities. These disparities were not explained by neighborhood SES.

Psychological Comfort of Paramedics with Field Death Pronouncement: A National Asian Study to Prepare Paramedics for Field Termination of Resuscitation.

OBJECTIVES: Paramedics' decision to terminate field resuscitation without a physician present may depend on personal and external factors. This study investigates factors associated with paramedic psychological comfort with termination of resuscitation (TOR) to inform future training. METHODS: We administered an anonymous survey to all practicing paramedics in a large urban Asian Emergency Medical Services system where formal TOR training had not yet been conducted and field TOR was not routinely applied. The survey assessed psychological comfort using the validated Psychological Comfort Total (PCT) scale (summed score of 28 items, with higher scores representing greater comfort). We examined scores associated with four personal (prior resolution of personal loss, knowledge of survival probability, religious affiliation and experience with death pronouncements) and two external (location of patient and perceived trust of family) factors. Data were entered into Excel and analyzed by t-tests and ANOVA. RESULTS: Response rate was 73.6% (254/345). Respondents were 30.3 years (mean, SD 7.1) with 7.2 years (mean, SD 5.54) of practice experience. Over 60% had been involved in 6 or more field death pronouncements in the prior 12 months. Higher PCT scores were associated with prior resolution of personal loss and knowledge of survival probability. Lower PCT scores were associated with patient location in a public place and perceived family lack of trust. PCT scores were not associated with paramedic religious affiliation or number of prior death pronouncements. CONCLUSIONS: Paramedic psychological comfort with field death pronouncement is associated with personal and external factors. Since paramedic comfort is important for protocol adoption, TOR education should target not only knowledge, but also public arena management, communication skills for engaging with families, and help paramedics resolve prior personal loss.

Increasing neurologically intact survival after out-of-hospital cardiac arrest among elderly: Singapore Experience.

Objectives: With more elderly presenting with Out-of-Hospital Cardiac Arrests (OHCAs) globally, neurologically intact survival (NIS) should be the aim of resuscitation. We aimed to study the trend of OHCA amongst elderly in a large Asian registry to identify if age is independently associated with NIS and factors associated with NIS. Methods: All adult OHCAs aged ≥18 years attended by emergency medical services (EMS) from April 2010 to December 2019 in Singapore was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Cases pronounced dead at scene, non-EMS transported, traumatic OHCAs and OHCAs in ambulances were excluded. Patient characteristics and outcomes were compared across four age categories (18-64, 65-79, 80-89, ≥90). Multivariable logistic regression analysis determined the factors associated with NIS. Results: 19,519 eligible cases were analyzed. OHCA incidence increased with age almost doubling in octogenarians (from 312/100,000 in 2011 to 652/100,000 in 2019) and tripling in those ≥90 years (from 458/100,000 in 2011 to 1271/100,000 in 2019). The proportion of patients with NIS improved over time for the 18-64, 65-79- and 80-89-years age groups, with the greatest improvement in the youngest group. NIS decreased with each increasing year of age and minute of response time. NIS increased in the arrests of presumed cardiac etiology, witnessed and bystander CPR. Conclusions: Survival with good outcomes has increased even amongst the elderly. Regardless of age, NIS is possible with good-quality CPR, highlighting its importance. End-of-life planning is a complex yet necessary decision that requires qualitative exploration with elderly, their families and care providers.

Machine learning prediction of refractory ventricular fibrillation in out-of-hospital cardiac arrest using features available to EMS.

Background: Shock-refractory ventricular fibrillation (VF) or ventricular tachycardia (VT) is a treatment challenge in out-of-hospital cardiac arrest (OHCA). This study aimed to develop and validate machine learning models that could be implemented by emergency medical services (EMS) to predict refractory VF/VT in OHCA patients. Methods: This was a retrospective study examining adult non-traumatic OHCA patients brought into the emergency department by Singapore EMS from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Data from April 2010 to March 2020 were extracted for this study. Refractory VF/VT was defined as VF/VT persisting or recurring after at least one shock. Features were selected based on expert clinical opinion and availability to dispatch prior to arrival at scene. Multivariable logistic regression (MVR), LASSO and random forest (RF) models were investigated. Model performance was evaluated using receiver operator characteristic (ROC) area under curve (AUC) analysis and calibration plots. Results: 20,713 patients were included in this study, of which 860 (4.1%) fulfilled the criteria for refractory VF/VT. All models performed comparably and were moderately well-calibrated. ROC-AUC were 0.732 (95% CI, 0.695 - 0.769) for MVR, 0.738 (95% CI, 0.701 - 0.774) for LASSO, and 0.731 (95% CI, 0.690 - 0.773) for RF. The shared important predictors across all models included male gender and public location. Conclusion: The machine learning models developed have potential clinical utility to improve outcomes in cases of refractory VF/VT OHCA. Prediction of refractory VF/VT prior to arrival at patient's side may allow for increased options for intervention both by EMS and tertiary care centres.

Variable importance analysis with interpretable machine learning for fair risk prediction.

Machine learning (ML) methods are increasingly used to assess variable importance, but such black box models lack stability when limited in sample sizes, and do not formally indicate non-important factors. The Shapley variable importance cloud (ShapleyVIC) addresses these limitations by assessing variable importance from an ensemble of regression models, which enhances robustness while maintaining interpretability, and estimates uncertainty of overall importance to formally test its significance. In a clinical study, ShapleyVIC reasonably identified important variables when the random forest and XGBoost failed to, and generally reproduced the findings from smaller subsamples (n = 2500 and 500) when statistical power of the logistic regression became attenuated. Moreover, ShapleyVIC reasonably estimated non-significant importance of race to justify its exclusion from the final prediction model, as opposed to the race-dependent model from the conventional stepwise model building. Hence, ShapleyVIC is robust and interpretable for variable importance assessment, with potential contribution to fairer clinical risk prediction.

Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest.

BACKGROUND: Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management. METHODS: Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated. RESULTS: A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR. CONCLUSION: The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

Impact of time-to-compression on out-of-hospital cardiac arrest survival outcomes: A national registry study.

OBJECTIVE: We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation. METHODS: All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval. RESULTS: 12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97-0.98); survival to discharge- aOR 0.98 (95%CI: 0.98-0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests. CONCLUSION: We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional 'down-times', which could aid clinical decisions in TOR or OHCA management.

Does witness type affect the chance of receiving bystander CPR in out-of-hospital cardiac arrest?

OBJECTIVES: The relationship between the bystander witness type and receipt of bystander CPR (BCPR) is not well understood. Herein we compared BCPR administration between family and non-family witnessed out-of-hospital cardiac arrest (OHCA). BACKGROUND: In many communities, interventions in the past decade have contributed to an increased receipt of BCPR, for example in Singapore from 15% to 60%. However, BCPR rates have plateaued despite sustained and ongoing community-based interventions, which may be related to gaps in education or training for various witness types. The purpose of this study was to investigate the association between witness type and BCPR administration. METHODS: Singapore data from 2010-2020 was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) network registry (n = 25,024). All adult, layperson witnessed, non-traumatic OHCAs were included in this study. RESULTS: Of 10,016 eligible OHCA cases, 6,895 were family witnessed and 3,121 were non-family witnessed. After adjustment for potential confounders, BCPR administration was less likely for non-family witnessed OHCA (OR 0.83, 95% CI 0.75, 0.93). After location stratification, non-family witnessed OHCAs were less likely to receive BCPR in residential settings (OR 0.75, 95% CI 0.66, 0.85). In non-residential settings, there was no statistically significant association between witness type and BCPR administration (OR 1.11, 95% CI 0.88, 1.39). Details regarding witness type and bystander CPR were limited. CONCLUSION: This study found differences in BCPR administration between family and non-family witnessed OHCA cases. Elucidation of witness characteristics may be useful to determine populations that would benefit most from CPR education and training.

Predictive performance of emergency department-specific variables on COVID-19 pneumonia.

Introduction: The majority of patients with COVID-19 infection do not progress to pneumonia. We report emergency department (ED)-specific variables and evaluate their predictive performance on diagnosis of pneumonia, intensive care unit (ICU) admission and death. Methods: This was a retrospective, single-centre cohort study of confirmed COVID-19 patients admitted to a Singapore tertiary hospital. Primary outcome was diagnosis of COVID-19 pneumonia. Secondary outcomes were ICU admission and/or death. Multivariate logistic regression was used to analyse the predictive performance of ED-specific variables. Accuracy of continuous variables was measured by area under receiver operating characteristic (ROC) curve. Results: 294 patients were included. Patients with pneumonia were older (52.0 years, P < 0.001) and had higher C-reactive protein (CRP; 33.8 mg/L, P < 0.001). Patients with indeterminate chest radiograph (CRX) findings were at risk of pneumonia vs. patients with normal CRX (37.5% vs. 4.3%, P < 0.001). Patients admitted to ICU were older (60.0 years, P < 0.001) and had higher CRP (40.0 mg/L, P < 0.001). Diagnosis of COVID-19 pneumonia was associated with ICU admission and death (30.0% vs 0.39%, P < 0.001). Multivariate logistic regression analysis showed that age (aOR 1.07, P = 0.049), CRP (aOR 1.05, P = 0.006) and CRX findings (aOR 50.00, P < 0.001) had increased odds of pneumonia. ROC curve analysis showed that CRP of 23.3 mg/L was the optimal cut-off for predicting pneumonia. Conclusion: Older age, higher CRP and CRX findings are associated with COVID-19 pneumonia, ICU admission and death. Prospective studies should be undertaken to validate these findings.

Longitudinal Study Comparing Mental Health Outcomes in Frontline Emergency Department Healthcare Workers through the Different Waves of the COVID-19 Pandemic.

As countries transition from the COVID-19 pandemic to endemic status, healthcare systems continue to be under pressure. We aimed to quantify changes in depression, anxiety, stress and post-traumatic stress disorder (PTSD) between 3 cohorts (2020, 2021 and 2022) of our Emergency Department (ED) healthcare workers (HCWs) and those who had worked through all 3 phases of the pandemic; and identify factors associated with poorer mental health outcomes (MHOs). In this longitudinal single-centre study in Singapore, three surveys were carried out yearly (2020, 2021 and 2022) since the COVID-19 outbreak. Depression, anxiety and stress were measured using DASS-21, and PTSD was measured using IES-R. A total of 327 HCWs (90.1%) participated in 2020, 279 (71.5%) in 2021 and 397 (92.8%) in 2022. In 2022, ED HCWs had greater concerns about workload (Mean score ± SD: 2022: 4.81 ± 0.86, vs. 2021: 4.37 ± 0.89, vs. 2020: 4.04 ± 0.97) and perceived to have less workplace support (2022: 4.48 ± 0.76, vs. 2021: 4.66 ± 0.70, vs. 2020: 4.80 ± 0.69). There was overall worsening depression (27.5% in 2020, 29.7% in 2021 and 32.2% in 2022) and stress (12.2% in 2020, 14.0% in 2021 and 17.4% in 2022). Healthcare assistants as a subgroup had improving MHOs. ED HCWs who were female and had psychiatric history, were living with the elderly, and had concerns about their working environment, workload and infection had poorer MHOs. This study will guide us in refining existing and devising more focused interventions to further support our ED HCWs' wellbeing.

A new paradigm in management of frequent attenders to emergency departments with severe alcohol use disorder-A pilot study for assertive community treatment in Singapore.

Introduction: A majority of frequent users of emergency medical services in Singapore present with alcohol-related problems. These patients are known to engage poorly with traditional addiction services and frequently attend Emergency Departments (EDs) instead, resulting in high healthcare burden. Assertive Community Treatment (ACT) is an alternative intervention to traditional addiction management. ACT involves community visits with focus on holistic care and harm-reduction. Materials and methods: We conducted a prospective before-and-after cohort study at the major tertiary center for addiction disorders in Singapore. The main objective was to evaluate effectiveness of ACT in reducing alcohol-related attendances at EDs nationwide. Socio-demographics, alcohol-related ED attendances, and the Christo Inventory for Substance-misuse Services (CISS) scores were collected for the patients recruited from April 2018 to March 2019. Descriptive analyses and the Wilcoxon Signed-Rank Test were performed. Results: All 14 patients were male with a mean age of 55 years. There was a significant 45.3% reduction in average alcohol-related ED attendances from 6.8 (range 3-22, median 5.5) in the pre-intervention 6-month period, to 3.7 (range 0-28, median 1.5) in the post-intervention 6-month period (Z = -2.244, p = 0.025). CISS scores showed significant improvement from a pre-intervention median of 13.5 (range 9-16) to a post-intervention median of 6.5 (range 1-10, p = 0.001), corresponding to reduction in alcohol-related problem severity. Conclusion: This pilot study suggests that ACT can be effective in reducing alcohol-related ED attendances and alcohol-related problem severity in patients with AUD who frequently attend ED. A multicenter, prospective study using ACT for such patients across four hospitals in Singapore is currently underway.

Nationwide Alcohol-related visits In Singapore's Emergency departments (NAISE): A retrospective population-level study from 2007 to 2016.

INTRODUCTION: Excessive alcohol consumption is associated with increased morbidity and mortality, and its societal impact is substantial. The Nationwide Alcohol-related visits In Singapore Emergency departments study aims to characterise trends in ED visits involving acute and chronic alcohol consumption between 2007 and 2016. METHODS: Data from the Singapore Ministry of Health, comprising all ED visits in Singapore from 2007 to 2016, were used. The data were aggregated by year and analysed for changes in prevalence and rates of ED visits for acute and chronic alcohol consumption, broken down by age, gender and ethnicity. RESULTS: Over the study period, the number of ED visits involving alcohol consumption increased 98.3%, from 2236 in 2007 to 4433 in 2016. During the same period, the rate per 100 000 population increased 62.4% from 48.7 to 79.1, and total ED-related costs rose by 140%, from 528 680 to 1 269 638 SGD. The increase in alcohol-related visits rates and costs was higher than non-alcohol-related visits rates and costs, which increased by 12.1% and 115% respectively. While trends in acute and chronic alcohol-related ED visits stayed stable amongst women, they rose substantially in men. Older men aged 50-69 show the highest rates and rate of increase for both acute and chronic alcohol-related ED visits. DISCUSSION AND CONCLUSIONS: Alcohol-related visits contributed disproportionately to the increasing number of ED visits in Singapore between 2007 and 2016. Older men form the demographic with the highest rates and increase in rates of alcohol-related ED visits and form a potential group for targeted intervention.

Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns.

INTRODUCTION: The burden of frequent attenders (FAs) of emergency departments (EDs) on healthcare resources is underestimated when single-centre analyses do not account for utilisation of multiple EDs by FAs. We aimed to quantify the extent of multiple ED use by FAs and to characterise FAs. METHODS: We reviewed nationwide ED attendance in Singapore data from 1 January 2006 to 31 December 2018 (13 years). FAs were defined as patients with ≥4 ED visits in any calendar year. Single ED FAs and multiple ED FAs were patients who attended a single ED exclusively and ≥2 distinct EDs within the year, respectively. Mixed ED FAs were patients who attended a mix of a single ED and multiple EDs in different calendar years. We compared the characteristics of FAs using multivariable logistic regression. RESULTS: We identified 200,130 (6.3%) FAs who contributed to1,865,704 visits (19.6%) and 2,959,935 (93.7%) non-FAs who contributed to 7,671,097 visits (80.4%). After missing data were excluded, the study population consisted of 199,283 unique FAs. Nationwide-linked data identified an additional 15.5% FAs and 29.7% FA visits, in addition to data from single centres. Multiple ED FAs and mixed ED FAs were associated with male sex, younger age, Malay or Indian ethnicity, multiple comorbidities, median triage class of higher severity, and a higher frequency of ED use. CONCLUSION: A nationwide approach is needed to quantify the national FA burden. The multiple comorbidities and higher frequency of ED use associated with FAs who visited multiple EDs and mixed EDs, compared to those who visited a single ED, suggested a higher level of ED burden in these subgroups of patients. The distinct characteristics and needs of each FA subgroup should be considered in future healthcare interventions to reduce FA burden.

Why Are Some Male Alcohol Misuse Disorder Patients High Utilisers of Emergency Health Services? An Asian Qualitative Study.

BACKGROUND: Certain alcohol misuse patients heavily utilise the Emergency Department (ED) and Emergency Medical Services (EMS) and may present with intoxication or long-term sequelae of alcohol misuse. Our study explored reasons for repeated ED/EMS utilisation and sought to understand perpetuating and protective factors for drinking. METHODS: Face-to-face semi-structured qualitative interviews were conducted. Participants were recruited from an ED in Singapore. Interviews were audio-recorded, transcribed verbatim and underwent manual thematic analysis. Emergent themes were independently reviewed for agreement. Data from medical records, interview transcripts, and field notes were triangulated for analysis. RESULTS: All participants were male (n = 20) with an average age of 55.6 years (SD = 8.86). Most were unemployed (75%), did not have tertiary education (75%), were divorced (55%), and had pre-existing psychiatric conditions (60%) and chronic cardiovascular conditions (75%). Reasons for utilisation included a perceived need due to symptoms, although sometimes it was bystanders who called the ambulance. ED/EMS was preferred due to the perceived higher quality and speed of care. Persistent drinking was attributed to social and environmental factors, and as a coping mechanism for stressors. Rehabilitation programs and meaningful activities reduced drinking tendencies. CONCLUSION: ED/EMS provide sought-after services for alcohol misuse patients, resulting in high utilisation. Social and medical intervention could improve drinking behaviours and decrease overall ED/EMS utilisation.