Poor performance of the modified early warning score for predicting mortality in critically ill patients presenting to an emergency department

BACKGROUND:This study was undertaken to validate the use of the modified early warning score(MEWS) as a predictor of patient mortality and intensive care unit(ICU)/ high dependency(HD)admission in an Asian population.METHODS:The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department(ED) between November 2006 and December2007.Individual MEWS was calculated based on vital signs parameters on arrival at ED.Outcomes of mortality and ICU/HD admission were obtained from hospital records.The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed.Sensitivity,specificity,positive and negative predictive values were derived and compared with values from other cohorts.A MEWS of ≥4 was chosen as the cut-off value for poor prognosis based on previous studies.RESULTS:A total of 311(30.4%) critically ill patients were presented with a MEWS ≥4.Their mean age was 61.4 years(SD 18.1) with a male to female ratio of 1.10.Of the 311 patients,53(17%)died within 30 days,64(20.6%) were admitted to ICU and 86(27.7%) were admitted to HD.The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0%and a specificity of 72.1%in addition to a positive predictive value(PPV) of 17.0%and a negative predictive value(NPV)of 93.4%(MEWS cut-off of ≥4) for predicting mortality.CONCLUSION:The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.

Early diagnosis of bowel obstruction and strangulation by computed tomography in emergency department

Closed loop bowel obstruction is a specific type of mechanical obstruction with a high risk of strangulation and bowel infarction, especially in the small bowel. It is associated with a high mortality rate. Hence, it is important for emergency physicians to identify the presence of strangulation, while making the diagnosis of closed loop small bowel obstruction. We reported three patients with strangulated closed loop small bowel obstruction associated with severe abdominal pain, who had been treated at the emergency department. Urgent computerized tomography was performed in the patients. Two patients were discharged with stable conditions, and one patient died after hemodialysis. Urgent computerized tomography of the abdomen serves as an important diagnostic tool in view of its ability to detect the site, level and cause of obstruction along with the distinctive CT appearance of closed loop small bowel obstruction and signs of ischemia. Early definitive diagnosis will guide subsequent management and improve outcomes.

Medical students as disaster volunteers:A strategy for improving emergency department surge response in times of crisis

Disasters resulting in mass casualty incidents can rapidly overwhelm the Emergency Department(ED).To address critical manpower needs in the ED’s disaster response,medical student involvement has been advocated.Duke-National University of Singapore Medical School is in proximity to Singapore General Hospital and represents an untapped manpower resource.With appropriate training and integration into ED disaster workflows,medical students can be leveraged upon as qualified manpower.This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps-a programme where medical students were recruited to receive regular training and assessment from emergency physicians on disaster response principles to fulfil specific roles during a crisis,while working as part of a team under supervision.We discuss overall strategy and benefits to stakeholders,emphasizing the close symbiotic relationship between academia and healthcare services.

Mobile technology:Usage and perspective of patients and caregivers presenting to a tertiary care emergency department

BACKGROUND:Developments in information technology(IT)have driven a push in healthcare innovation in the emergency department(ED).Many of these applications rely on mobile technology(MT)such as smartphones but not everyone is comfortable with MT usage.Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED.METHODS:A cross-sectional survey was conducted in the emergency department of a tertiary hospital.Patients and their caregivers aged 21 and above were recruited.The survey collected demographic information,technology usage patterns,and participant reported comfort level in the usage of MT.We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT.RESULTS:A total of 498 participants were recruited,and 299(60%)were patients.English was the most commonly written and read language(66.9%)and 64.2%reported a comfort level of 3/5 or more in using MT.Factors that were associated with being comfortable in using MT include having a tertiary education,being able to read and write English,as well as being a frequent user of IT.Caregivers were more likely to display these characteristics.CONCLUSION:A large proportion of ED patients are not comfortable in the usage of MT.Factors that predicted comfort level in the usage of MT were common amongst caregivers.Future interventions should take this into consideration in the design of MT interventions.

Diagnostic value of biomarkers for sepsis in adult patients in the emergency department: Don't forget the neutrophil-lymphocyte count ratio

Objective: To determine and compare the diagnostic efficiency of various biomarkers [C-reactive protein, neutrophil percentage, neutrophil-lymphocyte ratio (NLCR), lactate, procalcitonin, blood culture] in the identification of septic patients in emergency department (ED), and to assess the predictive value of combination of markers. Methods: This was a prospective, single centre study conducted in the ED of an urban, tertiary care hospital. We included patients who were admitted to the ED with symptoms of a possible infection. Blood cultures and serum measurement of the biomarkers were collected from 131 patients. Patients were determined to be septic or non-septic, based on the systemic inflammatory response syndrome criteria and the diagnosis was made at the ED. Sensitivity, specificity, positive predictive value, negative predictive value and area under curves (AUC) were calculated. Results: A total of 126 patients, 61 with sepsis and 65 without sepsis were eventually included in the study. Neutrophil to lymphocyte ratio displayed the highest accuracy in diagnosing sepsis (AUC 0.735, 95% CI=0648-0.822, P<0.001). The best combination of markers in predicting sepsis was NLCR and white blood cell (AUC: 0.801, 95% CI=0.724-0.878, P<0.001). Conclusions: The results of this small study showed that NLCR outperforms other markers in diagnosing sepsis in ED. It is readily available, cost efficient, non invasive and independent. It may be insufficient to rely on this single marker to diagnose sepsis, so some other diagnostic utilities should be taken into account as one part of the overall assessment. Our study also showed that combination of NLCR and white blood cell provides the highest diagnostic accuracy. More large scale studies across different population groups will be needed to confirm this finding.

Potential impact of early physiotherapy in the emergency department for non-traumatic neck and back pain

BACKGROUND: Musculoskeletal complaints, especially non-traumatic neck and back pain, are routinely encountered in the emergency department(ED) and lead to ED overcrowding, a burgeoning wait time for physiotherapy and outpatient orthopedic reviews. The study aimed to evaluate the impact of early physiotherapy evaluation and treatment(EPET) vs. standard care(SC) on clinical outcomes for patients presenting to the ED with non-traumatic neck and back pain.METHODS: A retrospective observational study of 125 patients who presented to the ED with non-traumatic neck and back pain with/without peripheral symptoms from July 2010 to February 2011. Neck Disability Index(NDI), Modifi ed Oswestry Low Back Pain Disability Questionnaire(MODI) and 11-point Numeric Pain Rating Scale were used as outcome measures and compared between groups at a mean of 34 days from their initial ED visit.RESULTS: We identifi ed a total of 125 patients. EPET group comprised 62 patients(mean age, 45 years; men, 63%) and SC group comprised 63 patients(mean age, 45 years; men, 43%). The EPET and SC groups received physiotherapy at a median of 4 and 34 days respectively from their fi rst ED visit. EPET patients had signifi cantly lower levels of disability(9.0% vs. 33.4%, Welch t-test, P<0.001) and pain(median value, 1 vs. 4 points, Mann-Whitney U-test, P<0.001) compared with SC patients.CONCLUSION: Early access to physiotherapy in ED was associated with reduced pain and disability levels. EPET protocol can potentially decrease the demand on outpatient orthopedic services, thereby freeing up available resources to treat patients who are more likely to benefi t from it.

Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

Association between the elderly frequent attender to the emergency department and 30-day mortality： A retrospective study over 10 years

BACKGROUND: To determine if elderly frequent attenders are associated with increased 30-day mortality, assess resource utilization by the elderly frequent attenders and identify associated characteristics that contribute to mortality. METHODS: Retrospective observational study of electronic clinical records of all emergency department(ED) visits over a 10-year period to an urban tertiary general hospital in Singapore. Patients aged 65 years and older, with 3 or more visits within a calendar year were identified. Outcomes measured include 30-day mortality, admission rate, admission diagnosis and duration spent at ED. Chi-square-tests were used to assess categorical factors and Student t-test was used to assess continuous variables on their association with being a frequent attender. Univariate and multivariate logistic regressions were conducted on all significant independent factors on to the outcome variable(30-day mortality), to determine factor independent odds ratios of being a frequent attender.RESULTS: 1.381 million attendance records were analyzed. Elderly patients accounted for 25.5% of all attendances, of which 31.3% are frequent attenders. Their 30-day mortality rate increased from 4.0% in the first visit, to 8.8% in the third visit, peaking at 10.2% in the sixth visit. Factors associated with mortality include patients with neoplasms, ambulance utilization, male gender and having attended the ED the previous year.CONCLUSION: Elderly attenders have a higher 30-day mortality risk compared to the overall ED population, with mortality risk more marked for frequent attenders. This study illustrates the importance and need for interventions to address frequent ED visits by the elderly, especially in an aging society.

Management of difficult intravenous access:a qualitative revie

BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy.As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other“tricks-of-the-trade”and pearls for overcoming DIVA are mostly relegated to informal nonpublished material,this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.METHODS:We conducted a literature search on PubMed using the keywords“difficult intravenous access”,“peripheral vascular access”and“peripheral venous access”and searched emergency medicine and anaesthesiology resources for relevant material.These strategies were then categorized and incorporated into a DIVA algorithm.RESULTS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept:starting off with standard peripheral intravenous cannulation(PIVC)techniques,progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.CONCLUSION:DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with.It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

A case of persistent refractory hypoglycemia from polysubstance recreational drug use

Dear editor,Studies have revealed a significant prevalence of mixed substance abuse,[1-3]and a focused approach towards polysubstance use has been emphasized.[4]Among recreational drugs,cases of hypoglycemia from ecstasy,[5]amphetamine,[6]eutylone,[7]and cannabinoid[8]use have been reported,but none of these cases have had persistent refractory hypoglycemia.

Comparing lignocaine-adrenaline-tetracaine gel with lignocaine infiltration for anesthesia during repair of lacerations:A randomized trial

BACKGROUND:This study aimed to compare the topical anesthetic lignocaine,adrenaline,and tetracaine(LAT)(4%lignocaine,1:2 000 adrenaline,1%tetracaine) with the conventional lignocaine infiltration(LI) for repair of minor lacerations,for the comfort of anesthetic administration,efficacy,adverse effects and cost.METHODS:This was a prospective randomized clinical trial.Forty Asian patients who required toilet and suture for minor lacerations in the emergency department of the Singapore General Hospital over a 4-month period.The patients were assigned randomly to 2 arms of treatment.The first was the LAT gel group who had LAT gel applied to the laceration prior to suturing.The second was the control group in whom the anesthetic administered was lignocaine infiltration(LI) via a syringe.The pain of the process of administering anesthetic and efficacy of anesthesia were scored using the visual pain scale included within.The efficacy of LAT vs.lignocaine infiltration as an anesthetic prior to the toilet and suture of minor lacerations and complications of therapy.RESULTS:Twenty patients were randomized to LAT gel and 16 to LI on an intention to treat analysis.The mean pain score by patients in the LAT gel group was 2.5(0.52 SE),and 2.5(0.58 SE)in the LI group.The pain score for pain during application of the anesthetic was 1.5(0.40) in the LAT gel group,and 3.5(0.46) in the LI group.There was no difference in complications between the LAT and LI groups.CONCLUSION:LAT gel prior to the toilet and suture of minor lacerations is proven to be as efficacious as LI in terms of patient comfort and effectiveness of anesthesia.The complications are also comparable to those treated with LI.

Venous thromboembolism in a healthy young man:An unintended consequence of coronavirus disease 2019 pandemic lockdown

Dear editor,The coronavirus disease 2019(COVID-19)pandemic has enveloped the globe with ferocious pace,prompting lockdowns of countries and continents.Consequently,up to one-third of the world’s population is living in some forms of coronavirus mass quarantine,which brings new and unprecedented challenges to healthcare systems worldwide.One of these is the potentially deleterious effects of physical inactivity due to enacted restrictions.

Hemorrhagic pancreatitis from fenofibrate and metformin toxicity:a case report

Fibrates have been used for over forty-odd years to manage dyslipidemia and are generally considered safe and well-tolerated.^([1])However,little is known about the toxicity offibrates in overdose,[2]and most of the knowledge about fibrate toxicity comes from extrapolated observations of adverse effects encountered at therapeutic doses instead.

Acute kidney injury associated with consumption of starfruit juice: A case report

BACKGROUND This study aims to highlight the potential serious complications of acute kidney injury(AKI)resulting from the consumption of excessive amounts of starfruit,a common traditional remedy.CASE SUMMARY A 78-year-old male with a past medical history of hypertension,diabetes mellitus and hyperlipidemia without prior nephropathy presented to the emergency department(ED)with hiccups,nausea,vomiting and generalized weakness.In the preceding 1 wk,he had consumed 3 bottles of concentrated juice self-prepared from 1 kg of small sour starfruits.His serum creatinine was noted to be 1101μmol/L from baseline normal prior to his ED visit.He was diagnosed with AKI secondary to excessive starfruit consumption.CONCLUSION Consumption of starfruit can cause acute renal failure,with a good outcome when promptly identified and treated.

Implementation science:A critical but undervalued part of the healthcare innovation ecosystem

Healthcare systems face many competing demands and insufficient resources.Service innovations to improve efficiency are important to address this challenge.Innovations can range from new pharmaceuticals,alternate models of care,novel devices,and the use other technologies.Suboptimal implementation can mean lost benefits.This review article aims to highlight the role of implementation science,summarize how settings have leveraged this methodology to promote translation of innovation into practice,and describe our own experience of embedding implementation science into an academic medical center in Singapore.Implementation science offers a range of methods to promote systematic uptake of research findings about innovations and is gaining recognition worldwide as an important discipline for health services researchers.Health systems around the world have tried to promote implementation research in their settings by establishing(1)dedicated centers/programs,(2)offering funding,and(3)building knowledge and capacity among staff.Implementation science is a critical piece in the translational pathway of“evidence to innovation”.The three efforts we describe should be strengthened to integrate implementation science into the innovation ecosystem around the world.

Bicycle-related traumatic injuries: a retrospective study during COVID-19 pandemic

BACKGROUND:This study aimed to review bicycle-related injuries during the COVID-19 pandemic to assist with reinforcement or implementation of new policies for injury prevention.METHODS:This is a retrospective descriptive analysis of injuries sustained during cycling for patients 18 years old and above who presented to Singapore General Hospital from January to June 2021.Medical records were reviewed and consolidated.Descriptive analyses were used to summarize patient characteristics,and differences in characteristics subgrouped by triage acuity and discharge status were analyzed.RESULTS:The study included 272 patients with a mean age of 43 years and a male predominance(71.7%).Most presented without referrals(88.2%)and were not conveyed by ambulances(70.6%).Based on acuity category,there were 24(8.8%)Priority 1(P1)patients with 7 trauma activations,174(64.0%)and 74(27.2%)P2 and P3 patients respectively.The most common injuries were fractures(34.2%),followed by superficial abrasion/contusion(29.4%)and laceration/wound(19.1%).Thirteen(4.8%)patients experienced head injury and 85 patients(31.3%)were documented to be wearing a helmet.The majority occurred on the roads as traffic accidents(32.7%).Forty-two patients(15.4%)were admitted with a mean length of stay of 4.1 d and 17(6.3%)undergone surgical procedures.Out of 214(78.7%)discharged patients,no re-attendances or mortality were observed.In the subgroup analysis,higher acuity patients were generally older,with higher proportions of head injuries leading to admission.CONCLUSION:Our study highlights significant morbidities in bicycle-related injuries.There is also a high proportion of fractures in the young healthy male population.Injury prevention is paramount and we propose emphasizing helmet use and road user safety.

Comparison of two emergency medical services in Beijing and Hong Kong, China

To Out-of-hospital cardiac arrest (OHCA) is a major issue in emergency care worldwide. The incidence of OHCA is estimated to be 50 to 60 per 100,000 persons globally.Despite advances in treatment and technology, survival following OHCA remains low. There are multiple factors affecting the survival outcome. The type of emergency medical service (EMS) system is likely to be one of them. In Asia, the EMS structure and its service capability in terms of dispatch, airway management, and medications vary widely between communities. This study aimed to evaluate the survival outcomes of OHCA in Beijing and Hong Kong (HK), China and the effect of the type of EMS system on the survival outcomes for patients with OHCA.

Staphylococcal thoracic aortitis complicated by aortic dissection

BACKGROUND:The diagnosis of aortitis is often delayed as symptoms are largely nonspecific.We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection.METHODS:The patient presented with pyrexia of unknown origin,and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection.A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures.Aortic thrombus cultures were positive for coagulase negative Staphylococcus aureaus,and histology showed chronic dissection of the aorta.RESULTS:The patient was treated with intravenous cefazolin for a 6-week duration and made good progress.CONCLUSIONS:This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin.Timely diagnosis is essential as progression to catastrophic rupture may occur.

Death related to ethyl chloride inhalation abuse: a case report

Dear editor,Human exposure to hydrocarbons(HCs)is unavoidable given their wide usage in a variety of common products.Ethyl chloride(EC),a type of halogenated HC,has been used in the production of pharmaceuticals,dyes,and other chemicals used for industrial purposes.[1,2]EC was used as an anesthetic induction agent in the early 1900s.[3]Although its use as an inhalational agent has fallen out of favour,EC is still used as a topical pain medication today.[4]

Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore

Background Emergency medical services(EMS)is a critical link in the chain of stroke survival.We aimed to assess EMS use for stroke in Singapore,identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment.Methods The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore.Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment.results Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016,68%arrived via EMS.Patients who used EMS were older,were less likely to be female,had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease.Patients transported by EMS were more likely to receive rapid evaluation(door-to imaging time≤25 min 34.3%vs 11.1%,OR=2.74(95%CI 1.40 to 5.38))and were more likely to receive intravenous tissue plasminogen activator(tPA,22.8%vs 4.6%,OR=4.61(95%CI 3.52 to 6.03)).Among patients treated with tPA,patients who arrived via EMS were more likely to receive timely treatment than self-transported patients(door-to needle time≤60 min 52.6%vs 29.4%,OR=2.58(95%CI 1.35 to 4.92)).Conclusions EMS use is associated with timely stroke evaluation and treatment in Singapore.Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.