Acute Hospital In Singapore Research Articles

Mental health-related presentations to a tertiary emergency department during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has caused significant mental distress in populations globally. At the frontline of the pandemic, emergency departments (EDs) are the prime setting to observe the effects of the pandemic on the mental health of the population. We aimed to describe the trend of mental health-related ED attendances at an acute hospital in Singapore before and during the various stages of the COVID-19 pandemic. This is a retrospective, descriptive study of patients who presented to the ED between 1 January 2019 and 31 December 2020. Patients diagnosed with mental health-related systematised nomenclature of medicine who visited the ED during this period were identified and were placed into mental health diagnosis categories for analysis. A comparison was made between patients who presented before the pandemic (2019) and during the pandemic (2020). During the study periods, we identified 1,421 patients, of whom 27 were excluded due to non-mental health-related diagnoses, leaving 1,394 patients for analysis. There was a 36.7% increase in mental health-related ED presentations from 2019 to 2020. The proportion of higher-acuity mental health-related ED attendances and number of suicide attempts also increased. Our study described an increase in the proportion of high-acuity mental health-related ED attendances during the COVID-19 pandemic. Emergency physicians must be cognisant of the effects of the pandemic on mental health. Further research should be conducted to better equip the healthcare system for handling all aspects of the pandemic.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study.

To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. A mixed-methods study. Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. No patients, service users, care-givers or members of the public were involved in the study.

Generational effect on nurses’ work values, engagement, and satisfaction in an acute hospital

BackgroundThe present nursing workforce comprises four generational of nurses working side–by–side. While such a generation blend adds invaluable diversity to the workforce, it also brings added complexity. The study aimed to describe and summarise work values and attitudes of four nursing generations, namely Baby boomers, Generation X, Y and Z.MethodA cross-sectional questionnaire study was adopted. A total of 778 nurses from an acute hospital in Singapore completed the online questionnaire. The Work Value and Attitude scale measuring seven constructs (Work Centrality, Non-compliance, Technology Challenge, Work life balance, leadership, Power, and Recognition) was employed for data collection.ResultsThe Cronbach’s alpha was 0.714 for the overall instrument. Statistically significant differences amongst the four generations of nurses emerged in the Work Value and Attitude scale in the construct of non-compliance (p = 0.007), technology challenge (p = 0.027), work-life balance (p < 0.001), and recognition (p < 0.001). No statistically significant differences were noted for the rest of the constructs.Discussion and conclusionThe findings of this study highlight that differences in work values and attitudes exist among nurses of different generations. Generation X are less likely to challenge the conventional norm and supervisors. Generation Y and Z are the most tech-savvy generations and can adapt quickly to new technology. There is also a greater emphasis on work-life balance as the generation gets younger. Generation Y and Z nurses perceived that younger nurses do not get due respect and recognition from their colleagues. Acknowledging the generational differences in work values and attitudes can facilitate nursing management to tailor strategies to improve individual and organisation performance while creating a work environment that enhances intergeneration harmony and teamwork.

A Phenomenological Investigation Into the Meaning of Food in Palliative Care Patients With Anorexia.

Little has been published on the meaning of food to palliative care patients with anorexia. Our study aims to investigate the meaning of food in palliative patients with anorexia. Fifteen patients with anorexia were recruited from the Palliative Care Unit of an acute hospital in Singapore from August 2018 to August 2021. A phenomenological methodology was employed to study the lived experience of anorexia and the meaning of food to palliative care patients. Our study findings revealed that food has social, physical, and emotional meaning in palliative care patients with anorexia. The social meaning of food was the predominant theme. Food was viewed as an important tool to bond and connect with their loved ones. It was perceived to be more important than the food itself and the taste of food was enhanced through social interactions. Food intake was related to physical strength and health status. Patients regarded eating as a way to improve their health status. Emotionally, eating was associated with positive feelings like enjoyment and freedom. Half of our participants felt that anorexia contributed to their low mood. Therefore, unlike the traditional focus of modifying the taste and quality of food in patients with anorexia, the authors recommended a focused assessment and management of the social aspect of anorexia on individual. This is important to mitigate the negative impact of anorexia, thus improving the quality of life and increasing their dignity towards the end of their lives.

Evaluating smoking cessation service at an emergency department clinical observation unit.

To evaluate the effectiveness of a pilot smoking cessation service in an emergency department (ED) clinical observation unit. A descriptive case series review was undertaken of smoking cessation service patients in the short-stay unit of an acute hospital in Singapore from July 1, 2018, to December 31, 2019. Upon admission, ED nurses screen all patients regarding their current smoking status and implement the 5 A's framework, which involves the steps of Ask-Advise-Assess-Assist-Arrange. Patients in the "contemplation" and "preparation" stages were offered the following components: (1) a bedside counseling session by a pharmacist and (2) a follow-up appointment at an outpatient smoking cessation clinic. Postdischarge follow-up telephone calls at 1, 6, and 12 months were carried out as part of the study data collection to obtain abstinence information. Forty-seven patients were included in the study; the majority were male (n = 41; 87.2%). The median numbers of cigarettes smoked per day at baseline, 1 month, 6 months, and 12 months were 14, 5, 3, and 5, respectively. The overall point-prevalence abstinence rates over the same follow-up time points were 26.5%, 38.7%, and 31.3%, respectively. The proportions of patients lost to follow-up at 1 month, 6 months, and 12 months were 27.7%, 34.0%, and 31.9%, respectively. Given the small sample and high number of uncontactable patients, more research is needed to assess whether the trend toward increasing point-prevalence abstinence rate over time and the trend toward decreasing median number of cigarettes smoked are observed in a larger sample.

Assessing the perceived indoor acoustic environment quality across building occupants in a tertiary-care public hospital in Singapore

Although hospitals are notorious for poor acoustics, the acoustic environment is usually evaluated in silos, or in conjunction with few indoor environmental quality (IEQ) factors. With only anecdotcal evidence, it is important to first establish a holistic baseline perception of the hospital acoustic environment before commissioning costly measurement campaigns. A psychometric questionnaire based on the industry-standard IEQ survey and ISO 12913-2 soundscape standard was administered to examine the perceived indoor acoustic environment quality across major occupant groups (i.e. staff, patients, visitors) in an acute hospital in Singapore. Of the 16 IEQ factors examined, all occupant groups expressed the greatest dissatisfaction with noise levels and sound privacy. Notably, the staff were significantly more dissatisfied than the other groups in terms of sound privacy and overall IEQ. When assessing the overall quality (OQ) and appropriateness (OA) of the acoustic environment, OQ was similarly neutral across all groups, whereas the staff expressed significantly lower OA than both patients and visitors. The dissatisfaction in the acoustic environment could be attributed to the perceived dominance and annoyance of vocal and operational sounds across all occupant groups, as well as the environment set-up with most being housed in cohort rooms. Particularly, the staff were significantly more annoyed with vocal and operational sounds than patients and visitors. This study also yielded evidence that challenges the validity of the 5-item Weinstein noise sensitivity scale when used in an Asian context, as well as the applicability of the perceived affective quality circumplex model in ISO 12913-3 for indoor environments.

Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital – an open-label stepped-wedge cluster-randomized trial

Background: The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. Aim: To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. Design: An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. Setting/participants: Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. Results: A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI −0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05–1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63–4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79–1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90–1.58, p = 0.215) were similar between the consult and co-rounding models. Conclusions: The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.

Helicobacter pylori knowledge and perception among multi-ethnic Asians.

Helicobacter pylori (HP) infection is endemic and causes peptic ulcer disease and gastric cancer. There is a lack of data related to awareness of the general public about HP and associated health risks. The objective of this study was to investigate the awareness and public perceptions about HP and the attitudes towards screening. This cross-sectional study included a structured 19-item questionnaire targeting members of the general public at a restructured acute hospital in Singapore. Out of 504 participants, 152 (30.2%) were aware of HP. Higher education was associated with HP awareness (p<0.001, OR 7.4, 95% CI 1.6-32.6). A third, 175 (34.7%) of the respondents identified the stomach as the primary site of infection. 131 (26.0%) respondents identified the fecal-oral route as a mode of transmission. 178 (35.3%) respondents were aware of available screening modalities, with around half of them willing to be screened with blood (n=256, 50.8%) or breath tests (n=265, 52.6%). 430 (85.3%) participants were keen to learn more about HP, and this was associated with age (p<0.05, OR 3.9, 95% CI 2.1-7.1). Awareness about HP infection is low, and acceptance of screening tests is high. Educational efforts are needed to improve awareness.

Challenges and opportunities in pragmatic implementation of a holistic hospital care model in Singapore: A mixed-method case study

IntroductionHospital-based practices today remain predominantly disease-oriented, focusing on individual clinical specialties with less visibility on a comprehensive picture of each patient’s health needs. To tackle the challenge of growing multimorbidity worldwide, practices without disease-specific focus have shown better integration of services. However, as we move away from the familiar disease-specific approaches of care delivery, many of us are still learning how to implement generalist care in a cost-effective manner.MethodsThis mixed-method case study, which centred on a specialist-led General Medicine model implemented at an acute hospital in Singapore, aimed to (1) quantitatively summarise its clinical outcomes, and (2) qualitatively describe the challenges and lessons gathered from the pragmatic implementation of the care model. Quantitative hospital data were extracted from databases and summarised. Qualitative staff-reported experiences and insights were gathered through semi-structured interviews and analysed using thematic analysis.ResultsQuantitative findings revealed that the generalist care model was implemented with high fidelity, where more than 75% of patients admitted were placed under General Medicine’s or General Surgery’s care. The mean length of stay was 2.6 days, and the 30-day post-discharge readmission rate was 15%. Inpatient mortality rate was found to be 2.8%, and the average gross hospitalisation bill amounted to SGD3,085.30. For qualitative findings, themes concerning feasibility and operational aspects of the implementation were grouped into categories- (1) Feasibility of ‘One Care Team’ approach, (2) Enablers required for meaningful generalist care, (3) Challenges surrounding information sharing, (4) Lack of integration with the community to facilitate care transition, and (5) Evolving roles of self-management. The findings were rich, with some being identified as barriers that could benefit from system-level de-constraining.DiscussionThis case study was an illustration of our pursuit for an integrated solution to rising prevalence of multimorbidity. While quantitative findings indicated that a pivot towards General Medicine might be possible, data also revealed gaps in clinical outcomes, especially in readmission rates. These findings corroborated with much of the lessons and challenges gathered from qualitative interviews, specifically surrounding the lack of receptacles in the community to facilitate care transition, training, and competency of generalists in holistic management of complex multimorbid cases, as well as inadequate infrastructure to allow information sharing between providers. Thus, a multi-pronged approach might be required to develop a new and sustainable care model for patients with multimorbidity in the long run. In the short to medium transitional period, nonetheless, the specialist-led General Medicine care model demonstrated might be a viable interim approach, especially in circumstances where trained medical generalists remained limited.

Performance of WHO and CDC influenza-like illness (ILI) case definitions in detecting influenza in the tropics

Background: Influenza-like illness (ILI) is defined by the World Health Organization (WHO) as an acute respiratory infection with onset within the past 10 days, presenting with cough and a measured temperature of >=38 °C, and the Centers for Disease Control and Prevention (CDC) as fever >=37.8 °C and cough and/or sore throat. We assessed for the performances of WHO and CDC ILI case definitions in the detection of influenza infections in a tropical country where seasonal patterns are less well-defined. Methods and materials: From June 2016 through Nov 2018, 717 consecutive adults presenting with uncomplicated upper respiratory tract infections (ICD10-AM J00-J06) at the emergency department of a 1600-bed acute hospital in Singapore were screened for 15 major respiratory viruses using a multiplex PCR respiratory virus pathogen panel (Seeplex RV15 ACE Detection), via throat and nasal swabs. Demographic, clinical, and epidemiological data were included to assess for the performances of WHO and CDC ILI case definitions in the detection of influenza infection, using multivariable logistic regression models. We also computed the sensitivities, specificities, and positive likelihood ratios (LR+) of the definitions. Results: The median age of participants was 36 (IQR 28–51) years. Two-thirds (67.8%) had no comorbidities. One-in-five (20.6%) patients tested positive for influenza and 14.4% for rhinovirus. Overall, 14.5% fulfilled the WHO ILI criteria and 20.8% the CDC ILI criteria. Performance of WHO ILI criteria in detecting influenza: sensitivity 38.5%, specificity 91.7%, and LR+ 4.7. Performance of CDC ILI criteria: sensitivity 48.7%, specificity 86.5%, and LR+ 3.6. After adjusting for age, comorbidities, influenza vaccination in the prior 6 months, travel history in preceding 7 days, month and year of illness presentation, patients fulfilling WHO ILI definition were nearly 7 times (Adj OR 6.81, 95%CI 4.22–11.00, p < 0.001) and those fulfilling the CDC ILI definition were 6 times (Adj OR 6.25, 95%CI 4.04–9.67, p < 0.001) as likely to have an influenza Infection respectively, than patients not fulfilling the criteria. Conclusion: The WHO and CDC ILI case definitions can be used to diagnose influenza infections in the tropics, regardless of the month of the year.

C-Reactive Protein (CRP) levels in influenza and other respiratory viral infections

Background: Viruses are major causes of upper respiratory tract infections (URTIs). Yet, antibiotics are commonly prescribed for URTIs. Point-of-care C-reactive protein (CRP) tests can be used to guide antibiotic prescribing for URTI. We sought to assess for the associations between CRP levels and influenza and other respiratory viral infections. Methods and materials: From June 2016 through November 2018, we screened 715 adults presenting with uncomplicated URTI (ICD10-AM J00-J06) at the emergency department of a 1600-bed acute hospital in Singapore for 15 major respiratory viruses using a multiplex PCR respiratory virus pathogen panel (Seeplex RV15 ACE Detection), via throat and nasal swabs, and CRP levels using a finger-prick point-of-care test (QuikRead go). We compared CRP levels between influenza and other viruses, and assessed for independent associations between CRP levels and influenza and other viral infections using multivariable multinomial logistic regression models. Results: Participants were young (median age 36 [IQR 28–51] years) and predominantly healthy (67.8% had no pre-existing illness). Almost half (48%) of them had a respiratory virus detected, with influenza (20.6%) and rhinovirus (14.4%) being the two most commonly detected viruses. CRP levels were significantly different between patients with influenza, other respiratory viruses, and no virus detected, with 32%, 46%, and 53% respectively having CRP ≤ 5 mg/L (P < 0.001). A CRP level of 6–20 mg/L was 1.7 times as likely to be associated with other respiratory viral infections (AOR 1.73, 95% CI 1.13–2.65) and 3.4 times as likely with an influenza infection (AOR 3.40, 95% CI 2.09–5.52) as a non-viral URTI, after adjusting for age, comorbidity, travel in the past 7 days, prior influenza vaccination within 6 months, month and year of illness episode. A CRP level of 21–40 mg/L was also twice as likely to be associated with an influenza infection (AOR 2.38, 95% CI 1.26–4.47) as a non-viral URTI. Conclusion: A mildly raised CRP level of 6–20 mg/L was more likely to be associated with a viral than non-viral URTI, although a higher CRP level of 21–40 mg/L was more suggestive of an influenza infection. Point-of-care CRP tests could provide clinical decision support for antibiotic use in uncomplicated URTIs.

Pressure injuries among admissions to a hospital in the tropics.

We report incidence rates for pressure injuries seen in an acute hospital in Singapore that were classified as Stage 3 or Stage 4. The characteristics of patients and the factors that explain variation in the primary outcome of duration of hospital stay are summarized. Existing data were available from Singapore General Hospital for all admissions from January 2016 to December 2019. Univariable analysis was done and a multivariable Poisson regression model estimated. Incidence rates declined from 4.05 to 3.4 per 1000 admissions in the 48 months between 2016 and 2019. The vast majority were community acquired with 75% in admission from the patients' home. Factors that explain variation in length of stay were, ethnicity; site of injury; community versus healthcare associated; inter-hospital transfer; fracture as reason for admission; and the number of days between admission and assessment of wound by specialist nurse. Stage 3 and 4 injuries arise in a home environment most often and are subsequently managed in acute hospital at high cost. These are novel epidemiological data from a hospital in the tropics where the potential to improve outcomes, implement screening and prevention, and thus increase the performance of health services is strong.

Evaluation of a Hospital-Based Nursing Research and Evidence-Based Practice Mentorship Program on Improving Nurses' Knowledge, Attitudes, and Evidence-Based Practice

Evidence-based practice (EBP) is a core requirement for nurses, contributing toward better clinical outcomes. Mentorship could prepare early adopters of EBP to create an EBP culture. Nine nurses in an acute hospital in Singapore participated in a mentorship program throughout 2015. Mentees conducted ward-based EBP education sessions for nursing colleagues. The Evidence-Based Practice Questionnaire (EBPQ) was used to measure the program's effect on mentees' and their ward colleagues' knowledge, attitude, and practice of EBP. Both groups completed the EBPQ before and 3 months after completion of the program. Wilcoxon rank-sum tests were performed to compare changes in EBPQ scores. Both mentees and ward colleagues reported improved posttest median scores for all EBPQ subscales and the overall score. However, mentees reported a larger magnitude of improvement. A hospital-based research and EBP mentorship program increases nurses' knowledge, attitude, and practice of EBP, creating an EBP culture change. [J Contin Educ Nurs. 2020;51(1):46-52.].

Jonsen's Four Topics Approach as a Framework for Clinical Ethics Consultation.

This was an in-depth qualitative study that looked at the reasons patients were referred to the Clinical Ethics Committee (CEC) of an acute hospital in Singapore and explore how the CEC approached cases referred. Jonsen's four topics approach was applied in the deliberative process for all cases. A comprehensive review of the case records of 28 patients referred consecutively to the CEC from 1 January 2012 to 31 December 2014 was conducted. Data and information was collated from the referral forms, patient medical records, and emails communicated among CEC members. A deductive approach to thematic analysis based on Jonsen's four topics approach was used to analyze the documents. Majority of the patients were male (94%), Chinese (76%), and above 65years of age (41%). Ethical dilemmas surfaced due to differences in opinion regarding withholding of aggressive management (53%), withdrawing treatment (35%), and ascertaining patient's autonomy (12%). In most cases, the patients' preference on end-of-life care was unknown (82%). The main reasons for referral to the CEC were conflicts in clinical management and uncertainty about the decision-making capacity of patients. The CEC members tended to emphasize on "patient preference" more than the other quadrants in the four topics approach as they worked through each case. The Jonsen's four topics approach lays the groundwork to frame ethical dilemmas that can be easily applied in the clinical setting and is a useful tool for the CEC's teaching and discussion. Nonetheless, the approach only organizes ethical dilemmas and requires clinicians to apply own judgment in weighing ethical principles. Further studies can look into adapting the four topics approach to suit the local practices and context.

A randomized controlled trial on a nurse-led smartphone-based self-management programme for people with poorly controlled type 2 diabetes: A study protocol.

To develop and compare a nurse-led smartphone-based self-management programme with an existing nurse-led diabetes service on health-related outcomes for people with poorly controlled type 2 diabetes in Singapore. Over the past decades, Asia has emerged as the "diabetes epicentre" in the world due to rapid economic development, urbanization and nutrition transition. There is an urgent need to develop more effective care management strategies in response to this rising diabetes epidemic. A randomized controlled trial with pre- and repeated posttests control group design. A total of 128 adults with poorly controlled type 2 diabetes will be recruited from the diabetes clinic of a public acute hospital in Singapore through convenience sampling. Study participants will be randomly allocated either to the experimental group or the control group. Outcome measures will include the 10-item General Self-Efficacy Scale, 11-item Revised Summary of Diabetes Self-care Activities and 19-item Diabetes-Dependent Quality of Life. Data will be collected at three time points: baseline, 3 and 6months from the baseline. It is expected that this programme will be an alternative offered to diabetes patients to master their self-care management skills, in addition to the existing diabetes service provided in diabetes clinics in Singapore hospitals. Furthermore, the self-supporting and less resource-intensive nature of this programme, using a smartphone application as the mode of intervention delivery, will greatly reduce nurses' direct contact time with patients and allow more time to be allocated to those who require more attention. The study has been registered with ClinicalTrials.gov. The trial registration number is NCT03088475.

Where to go if not the hospital? Reviewing geriatric bed utilization in an acute care hospital in Singapore.

Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients. We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns. Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity=62%; specificity=88%). In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.

Effectiveness of advanced practice nurse-led telehealth on readmissions and health-related outcomes among patients with post-acute myocardial infarction: ALTRA Study Protocol.

To develop and examine the effectiveness of an advanced practice nurse-led telehealth rehabilitative programme as a transitional nursing therapeutic on readmission rates and health-related outcomes among patients with acute myocardial infarction postdischarge. Patients suffering from acute myocardial infarction are experiencing an increasing trend of frequent readmissions. This implicates both the effectiveness of healthcare services and patient's quality of life. Advanced Practice Nurse-led telehealth rehabilitative programme has yet to be explored as a strategy to minimize preventable readmissions and improve patient's self-efficacy so as to enhance quality of life after a heart attack. Randomized controlled trial with repeated measures. A consecutive sampling of 172 patients with acute myocardial infarction will be recruited from a tertiary acute hospital in Singapore. Participants will be randomized into two groups. The experimental group (ALTRA) will receive Advanced Practice Nurse-led telehealth rehabilitative programme on discharge. The control group will receive only standard follow-up care. The outcome measures include readmissions, cardiac self-efficacy, cardiovascular risk factors, quality of life, anxiety and depression. The data will be collected at the baseline, 1 and 6month postdischarge. A postprogramme evaluation will be conducted among the participants to assess its acceptability, strengths and weakness. ALTRA aims to engage and support patients with acute myocardial infarction by increasing self-care management through education and telehealth contacts with Advanced Practices Nurses. This provides a smoother transition of illness to health and ultimately, reduces preventable costly readmissions. The study has been registered with clinicaltrials.gov. The trial registration number is NCT02483494.

The risk factors for hospital re-admission in medical patients in Singapore

Unplanned hospital re-admissions are common, expensive and often unpreventable in the community. The study aimed to identify risk factors associated with unplanned hospital re-admission in Singapore. In a cross-sectional survey, 1509 patients admitted to the medical wards of a large acute hospital in Singapore during 2010 were recruited (78.8% response rate), data being collected using a structured questionnaire based on the Andersen behavioural model underlying healthcare use. The dependent variable was re-admission within 28days, with independent variables in the four areas of predisposing characteristics, needs, enabling resources and health behaviour. Hierarchical logistic regression was used to evaluate the risk factors associated with unplanned hospital re-admission. There were 222 inpatients re-admitted (14.7%) within 28days and the final model showed that patients who were unemployed (OR=1.5; 95% CI=1.1-2.1) and had chronic obstructive pulmonary disease (OR=2.0; 95% CI=1.1-3.7) with abnormal respiratory patterns (OR=1.6; 95% CI=1.1-2.2) were more likely to be re-admitted. Less likely to be re-admitted were patients doing regular daily activities (OR=0.7; 95% CI=0.5-0.9), those assisted by a social worker (OR=0.3; 95% CI=0.2-0.6), those referred to other health professionals when sick (OR=0.6; 95% CI=0.4-0.7) and those who had received health education programmes before discharge in the previous admission (OR=0.7; 95% CI=0.4-0.9). Unplanned re-admissions are a concern to healthcare providers because this suggests that patients are discharged with unresolved problems that reflect ineffective care in hospital. This study provides evidence to prompt more effective discharge educational care programmes that incorporate patients' enabling and need outcomes, thereby reducing re-admission rates. Community-based healthcare should play an important role in reducing patients' re-admission rates.

Securing and Sustaining Employment: Concerns of HIV Patients in Singapore

Employment sustainability is one of the most pressing issues inflicting people living with HIV (PLHIV). A qualitative approach was used to elucidate the perceived challenges in sustaining their employment and the perceived barriers in re-entering the workforce for HIV patients. In-depth interviews were conducted with 16 patients from an acute hospital in Singapore. The main challenges raised in sustaining employment were: (1) ability to ensure secrecy of diagnosis from employers, (2) ability to secure financial resources for treatment and sustenance, (3) ability to ensure stable health to meet job requirements, (4) ability to cognitively sit with the concerns of uncertainty and limitations in career, and (5) ability to work through discriminatory workplace practices. The perceived barriers in gaining workforce re-entry were: (1) fear of pre-employment medical screening and potential discriminatory practices at workplace, (2) concerns over health (frequent hospital admissions, physical weakness, and existing medical co-morbidities), and (3) psychosocial challenges (unstable accommodation, older age, financial issues, and trade skills limitation). The overarching factor that influences the success of sustaining and securing an employment among HIV patients is secrecy of the diagnosis. The individuals' health status, financial status and access to healthcare, and other psychosocial challenges further compound the issue.

PHS86 - Develop And Validate A Risk Index To Predict 30 Days Emergency Hospital Readmission

Emergency hospital readmissions are costly to the health care system. Identifying high-risk patients and targeting intensive post-discharge interventions may help reduce readmissions. Thus, this study aims to develop and validate a predictive model to score patients’ risk of emergency hospital readmission in an acute hospital in Singapore.