Tertiary Care Hospital In Singapore Research Articles

Heat-related illness in Singapore: Descriptive analysis of a tertiary care center from 2008 to 2020

Background This study aimed to describe the clinical characteristics and epidemiology of heat-related illnesses presented at a tertiary hospital in Singapore. Method This retrospective observational study utilized electronic health records from the emergency department (ED) of Singapore General Hospital. Patients primarily diagnosed with heat-related illnesses from 2008 to 2020, were analyzed. The annual number of cases and the temporal trend of heat-related illnesses were described, along with the characteristics of patients. Results Among the 1,833,908 patients registered at the ED, 426 patients had diagnoses of heat-related illnesses. The median age (interquartile range [IQR]) was 32 (22, 43) years, with 303 (71%) being male and 201 (47%) not being Singapore citizens. The annual number of cases ranged from a minimum of 21 in 2019 to a maximum of 49 cases in 2015, except for four cases in 2020. Heat-related illnesses occurred most commonly on Sundays (233, 55%) and in December (97, 23%). A significant number of cases in December coincided with the day of an annually organized marathon (91, 21%). Approximately half of the total cases required hospitalization, with 183 (43%) admitted to the general ward and 31 (7%) admitted to the intensive care unit. The 30-day mortality was 2 (0.5%). Conclusion This descriptive study indicated the unique characteristics of heat-related illness in a tertiary care hospital in Singapore. These local contexts may be valuable to consider preventative measures for heat-related illness, in preparation for future extreme weather events related to climate change.

#109 : Differential Effects of Age and Lifestyle on Anti-Mullerian Hormone Levels and Ovarian Reserve in Asian Women with and Without Polycystic Ovarian Syndrome (PCOS)

Background and Aims: Polycystic ovarian syndrome (PCOS) afflicts 4-20% of all women at reproductive age and is a common cause of infertility. Elevated anti-Mullerian hormone levels (AMH), a clinical marker for ovarian reserve, are routinely associated with PCOS, however, an exact cut-off value has remained elusive. Interestingly, observational studies reported that women with PCOS have purported higher ovarian reserves, implied from higher AMH levels, and later age of menopause delayed by 2 years when compared to women without PCOS. Our study focuses on the Asian population, a demographic frequently under-represented in cohort studies. We posit that our results will bridge the gap in the collective understanding of PCOS and how age and lifestyle effects on ovarian reserves in Asian women. Method: A large retrospective study was conducted at a tertiary-care hospital in Singapore from 2016-2020. AMH and clinical demographics from 3,739 Asian women aged 21-53 years were collected. Wilcoxon Rank Sum was used to analyze the data and significance was established if p<0.05. Logistic regression and ROC were generated in R. Results: AMH (aOR=1.07), age (aOR=0.89) and BMI (aOR=1.12) were significantly associated with PCOS(p<0.001) in Asian women. AMH declined with age but the decline in the PCOS group was less severe, with 80% AMH retained in women in their 40s, as compared to controls which retained only 40% AMH(Fig. 1). BMI>25 and smoking status affected AMH levels with higher BMI and smoking associated with lower AMH. An ethnic stratification revealed that average AMH levels of Malay women with PCOS were lower than Chinese and Indian women in each age group (Fig. 2). The constructed model incorporating all variables had an ROC AUC=0.89. Conclusion: This study highlights the importance of improving the resolution of PCOS diagnosis through AMH profiling, especially in Asian populations. The results from this study suggest potential beneficial effects of lifestyle modifications such as maintaining a healthy BMI and stopping smoking, especially in Asian women with PCOS.

Harnessing a real-time location system for contact tracing in a busy emergency department

With the persistent threat of emerging infectious diseases (EID), digital contact tracing (CT) tools can augment conventional CT for the prevention of healthcare-associated infectious disease transmissions. However, their performance has yet to be comprehensively evaluated in the fast-paced emergency department (ED). We compared the CT performance of the radiofrequency identification (RFID) based real time location system (RTLS) with conventional Electronic Medical Records (EMR review), against continuous direct observations of close contacts ("gold-standard") in a busy ED during pandemic period. The cross-sectional study was conducted at the ED in a large tertiary-care hospital in Singapore, from December-2020 to April-2021. We computed the CT performance (sensitivity, specificity, PPV, NPV, kappa) of RTLS, EMR and combination of the 2 approaches (Hybrid-CT), with respect to the direct observations. Finally, we calculated the Mean Absolute Error (MAE) between the duration of each contact episode found via RTLS and direct observations. Both RTLS and the hybrid-CT approach had the highest sensitivity of 0.955 (vs EMR 0.455) and highest NPV of 0.997 (vs EMR 0.968). RTLS also had the highest PPV of 0.777 (vs EMR 0.714; vs hybrid-CT 0.712). RTLS had the strongest agreement with the direct observation (kappa= 0.848). MAE between contact durations of 80 direct observations and their respective RTLS contact time was 1.81 minutes. RTLS was validated to be a high-performing CT tool, with significantly higher sensitivity than conventional CT via EMR review. RTLS can be used with confidence in time-strapped EDs for time-sensitive CT for the prevention of healthcare-associated transmission of EIDs.

Optimizing Best Practice Advisory alerts in electronic medical records with a multi-pronged strategy at a tertiary care hospital in Singapore.

Clinical decision support (CDS) alerts can aid in improving patient care. One CDS functionality is the Best Practice Advisory (BPA) alert notification system, wherein BPA alerts are automated alerts embedded in the hospital's electronic medical records (EMR). However, excessive alerts can change clinician behavior; redundant and repetitive alerts can contribute to alert fatigue. Alerts can be optimized through a multipronged strategy. Our study aims to describe these strategies adopted and evaluate the resultant BPA alert optimization outcomes. This retrospective single-center study was done at Jurong Health Campus. Aggregated, anonymized data on patient demographics and alert statistics were collected from January 1, 2018 to December 31, 2021. "Preintervention" period was January 1-December 31, 2018, and "postintervention" period was January 1-December 31, 2021. The intervention period was the intervening period. Categorical variables were reported as frequencies and proportions and compared using the chi-square test. Continuous data were reported as median (interquartile range, IQR) and compared using the Wilcoxon rank-sum test. Statistical significance was defined at P < .05. There was a significant reduction of 59.6% in the total number of interruptive BPA alerts, despite an increase in the number of unique BPAs from 54 to 360 from pre- to postintervention. There was a 74% reduction in the number of alerts from the 7 BPAs that were optimized from the pre- to postintervention period. There was a significant increase in percentage of overall interruptive BPA alerts with action taken (8 [IQR 7.7-8.4] to 54.7 [IQR 52.5-58.9], P-value < .05) and optimized BPAs with action taken (32.6 [IQR 32.3-32.9] to 72.6 [IQR 64.3-73.4], P-value < .05). We estimate that the reduction in alerts saved 3600 h of providers' time per year. A significant reduction in interruptive alert volume, and a significant increase in action taken rates despite manifold increase in the number of unique BPAs could be achieved through concentrated efforts focusing on governance, data review, and visualization using a system-embedded tool, combined with the CDS Five Rights framework, to optimize alerts. Improved alert compliance was likely multifactorial-due to decreased repeated alert firing for the same patient; better awareness due to stakeholders' involvement; and less fatigue since unnecessary alerts were removed. Future studies should prospectively focus on patients' clinical chart reviews to assess downstream effects of various actions taken, identify any possibility of harm, and collect end-user feedback regarding the utility of alerts.

Contact tracing using a real-time location system in a tertiary-care hospital in Singapore

Background: Densely populated metropolitan cities like Singapore are susceptible to emerging infectious disease (EID) outbreaks. Singapore’s pandemic control measures include running biennial simulation exercises for all public hospitals on EID case management, in which a key assessment criterion is contact tracing. Current methods of contact tracing that involve retrospective review of the electronic medical record (EMR) are time-consuming and heavily manpower dependent, and they fail to capture a significant number of contacts. A real-time location system (RLTS) was accurate and effective in contact tracing. We compared the time taken to perform contact tracing and list of contacts identified for RTLS versus EMR, and we compared manpower and manpower hours required to perform contact tracing for RTLS versus EMR. Then we extrapolated the cost incurred by RTLS versus EMR. Methods: A prospective case study was conducted during a simulation exercise to determine and compare the list of contacts, time required, manpower required, and manpower hours required between RTLS and EMR. The costs of both methods were also compared. Results: RTLS identified almost 3 times more contacts than EMR (Fig. 2) with a 96.2% reduction in time taken, a 97.6% reduction in manpower, and a 97.5% reduction in manpower hours (Fig. 1). RTLS incurred significant equipment cost and therefore might require many contact-tracing episodes before providing economic benefit (Fig. 3). However, its speed and accuracy provided during contact tracing will allow the hospital to quickly isolate potentially exposed contacts, reducing the number of infected people during the spread of an infectious disease, particularly one like COVID-19. Conclusions: Albeit costly, RTLS is effective at contact tracing. RTLS has the potential to be the gold standard in contact-tracing methods of the future, particularly considering the current pandemic.Disclosures: None

Dissemination of Pseudomonas aeruginosa blaNDM-1-Positive ST308 Clone in Singapore.

Pseudomonas aeruginosa ST308 clone has been reported to carry carbapenemase genes such as blaIMP and blaVIM but has been rarely associated with blaNDM-1. A total of 199 P. aeruginosa ST308 clinical and environmental isolates obtained between April 2019 and November 2020 from a tertiary-care hospital in Singapore were characterized using whole-genome sequencing. In addition, 71 blaNDM-1-positive ST308 whole-genome sequences from two other local tertiary-care hospitals in Singapore and 83 global blaNDM-1-negative ST308 whole-genome sequences in public databases were included to assess phylogenetic relationships and perform genome analyses. Phylogenetic analysis and divergent time estimation revealed that blaNDM-1-positive P. aeruginosa ST308 was introduced into Singapore in 2005 (95 % highest posterior density: 2001 to 2008). Core genome, resistome, and analyses of all local blaNDM-1-positive ST308 isolates showed chromosomal integration of multiple antibiotic resistance genes (ARGs) [aac(3)-Id, aac(6')-Il, aadA6, aadA11, dfrB5, msr(E), floR, sul2, and qnrVC1], which was absent in global blaNDM-1-negative ST308 sequences. Most ARGs and virulence genes were conserved across isolates originating from the three different local hospitals. Close genetic relatedness of the blaNDM-1-positive ST308 clinical and environmental isolates suggests cocirculation between the hospital environment and human hosts with the hospital environment as a potential reservoir. Core genome single nucleotide polymorphism analyses revealed possible clonal transmission of blaNDM-1-positive ST308 isolates between the three hospitals over 7 years. Bloodstream isolates accounted for six of 95 (6.3%) clinical isolates. This study reports the introduction of a pathogenic blaNDM-1-positive P. aeruginosa ST308 more than a decade ago in Singapore and warrants surveillance for wider dissemination. IMPORTANCE P. aeruginosa is a Gram-negative opportunistic pathogen ubiquitously found in the environment and a major cause of nosocomial infections. While the P. aeruginosa ST308 clone has been known to bear blaIMP and blaVIM among global isolates, reports of blaNDM-1-positive P. aeruginosa ST308 are rare. The local blaNDM-1-positive P. aeruginosa ST308 isolates detected in this study appear to be unique to this region, with evidence of chromosomal acquisition of multiple ARGs compared to global blaNDM-1-negative P. aeruginosa ST308 isolates. Surveillance in Singapore and beyond for dissemination is essential to determine whether existing measures are sufficient to control the spread of this ST308 clone.

SG-APSIC1122: Observational study of handwashing sink activities in the inpatient setting

Objectives: The use of handwashing sinks for activities other than hand hygiene (HH) is associated with higher rates of β-lactamase–producing Enterobacteriaceae. However, little has been published about the handwashing sink activities in Singapore hospitals. We explored the handwashing sink activities in a tertiary-care hospital in Singapore. Methods: Five trained shadow observers conducted this observational study between December 18 and 21, 2018 (6 hours per day: 07:00–09:00, 09:30–11:30, and 12:30–14:30) in acute-care general wards. We divided the handwashing sink activities by healthcare workers (HCWs) and non-HCWs (ie, visitors, caregivers, and relatives) and by HH- and non–HH-related activities. We used Stata version 15 software for the analysis. The study was approved by the Institutional Review Board of the National Healthcare Group, Singapore (DSRB no. 2020/01257). Results: In total, 657 handwashing sink activities were recorded [HCWs, 475 (72.3%) and non-HCWs, 182 (27.7%)]. Of the 475 HCW handwashing sink activities, 451 (94.9%) were HH-related, 10 (2.1%) were for patient nutrition, 7 (1.5%) were for environmental care, 6 (1.3%) were for medical equipment cleaning, and 1 (0.2%) was patient personal-item cleaning. Of the 182 handwashing sink activities by non-HCWs, 117 (64.3%) were HH related, 30 (16.5%) were for patient nutrition, 21 (11.5%) were for personal hygiene, 14 (7.7%) were patient personal-item cleaning. The distribution of handwashing sink activities differed significantly (P &lt; .01) between HCWs and non-HCWs. The odds of non–HH-related handwashing sink activities among non-HCWs was 10× higher than among HCWs (OR, 10.44; 95% CI, 5.98–18.23; P &lt; .01). Conclusions: Handwashing sinks use for non–HH-related activities is higher among non-HCWs than HCWs. Further studies are needed to understand the impact of non-HH handwashing sink activities on nosocomial infections and ways to reduce them.

CORR Insights®: A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population.

CORR Insights®: A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population.

Medico-legal dispute resolution: Experience of a tertiary-care hospital in Singapore.

IntroductionThe resource burden of healthcare disputes and medico-legal claims has been rising. A dispute resolution system operating at the hospital level could ameliorate this disturbing trend.MethodsThis is a retrospective observational study on patient complaints and medico-legal cases received by the dispute resolution unit of an acute tertiary hospital from 2011 to 2015. We described the characteristics and analysed the resolution methodology and outcomes of all closed medico-legal cases.ResultsPatient complaints significantly increased at a compound annual growth rate (CAGR) of 4.2% (p<0.01), while medico-legal cases and ex-gratia payments for case settlements decreased at CAGRs of 4.8% (p<0.05) and 15.9% (p = 0.19), respectively. Out of 237 closed medico-legal cases, 88.6% were resolved without legal action, of which 78.1% were closed without any ex-gratia payments or waivers. Of the 11.4% of medico-legal cases that involved legal action, 66.7% were settled without ex-gratia payments or waivers. The primary resolution modes were the Patient Relations Service (PRS)’s engagement of the complainants and facilitation of written replies. No cases were brought to court. Cases were more likely resolved without legal action when there was engagement by the PRS (p = 0.009). These cases incurred a lower median settlement value than those with legal action.ConclusionOur hospital-based dispute resolution system which addressed patients’ core dissatisfactions and providers’ perspectives, through a process of early engagement, open disclosure, and fair negotiations, was able to promote claims resolution before legal action was taken. This early dispute resolution strategy contained costs and maintained provider-patient relationships and complements system-level mediation and arbitration to reduce medico-legal litigation.

COVID-19 among healthcare workers of a tertiary-care hospital in Singapore

Background: Singapore General Hospital (SGH) is the largest acute tertiary-care hospital in Singapore. Healthcare workers (HCWs) are at risk of acquiring COVID-19 in both the community and workplaces. SGH has a robust exposure management process including prompt contact tracing, immediate ring fencing, lock down of affected cubicles or single room isolation for patient contacts, and home isolation orders for staff contacts of COVID-19 cases during the containment phase of the pandemic. Contacts were also placed on enhanced surveillance with PCR testing on days 1 and 4 as well as daily antigen rapid tests (ARTs) for 10 days after exposure. Here, we describe the characteristic of HCWs with COVID-19 during the third wave of the COVID-19 pandemic. Methods: This retrospective observational study included all SGH HCWs who acquired COVID-19 during the third wave (ie, the 18-week period from September 1 to December 31, 2021) of the COVID-19 pandemic. Univariate analysis was used to compare characteristics of work-associated infection (WAI) and community-acquired infection (CAI) among HCWs. Results: Among a workforce of &gt;10,000 at SGH, 335 HCWs acquired COVID-19 during study period. CAI (exposure to known clusters or household contact) accounted for 111 HCW infections (33.1%). Also, 48 HCWs (14.3%) had a WAI (ie, acquired at their work places where there was no patient contact). Among WAsI, only 5 HCWs had hospital-acquired infection (confirmed by phylogenetic analysis). The sources of exposure for the remaining 176 HCWs were unknown. Weekly incidence of COVID-19 among HCWs was comparable to the epidemiology curve of all cases in Singapore (Fig. 1 and 2). The mean age of HCWs with COVID-19 was 39.6 years, and most were women. At the time of positive SARS-CoV-2 PCR test, 223 HCWs were symptomatic, and 67 (20.0%) of them had comorbidities. Only 16 HCWs (4.8%) required hospitalization, and all recovered fully with no mortality (Table 1). Being female was associated with community COVID-19 acquisition (OR, 4.6, P Conclusions: During the thrid wave of the COVID-19 pandemic, a higher percentage of HCWs at SGH acquired the infection from the community than from the workplace. Safe management measures, such as universal masking, social distancing, and robust exposure management processes including prompt contact tracing and environmental disinfection, can reduce the risk of COVID-19 in the hospital work environment.Funding: NoneDisclosures: None

Chronic Pain: Among Tertiary Care Psychiatric Out-Patients in Singapore-Prevalence and Associations with Psychiatric Disorders.

Objective The study aimed to determine the prevalence and severity of chronic pain and its associations amongst psychiatric out-patients in a tertiary care hospital in Singapore. Methodology. The cross-sectional study was conducted among 290 psychiatric out-patients aged 21–65 years. Sociodemographic and clinical information, as well as data from Brief Pain Inventory-Short Form (BPI-sf), Beck's Depression Inventory II (BDI-II), and Beck's Anxiety Inventory (BAI) were collected. Cut points (C.P.s) dividing the sample into mild, moderate, and severe groups were created for the ratings of average pain. Eight possible cut-off values for the C.P.s between 3 and 7, representing 8 different categorical variables, were created and their relationships were examined with BPI's set of seven interference items using multivariate analysis of variance. Sociodemographic and clinical correlates of chronic pain were determined using multinomial logistic regression analysis. Analysis of covariance was used to determine the association of BPI with continuous scores of BAI and BDI. Results Based on the C.P. pain severity classification, 38.5% of the sample had mild pain, 22.9% had moderate pain, and 11.8% had severe pain. Patients with severe pain were more likely to be associated with older age (p ≤ 0.006) (versus young age), less likely to be married (p ≤ 0.025) (versus single), and more likely to have high risk for obesity (p ≤ 0.030) (versus low risk for obesity). Participants with mild pain were seen to be significantly associated with older age (p ≤ 0.021), whereas moderate pain (p ≤ 0.002) and severe pain (p ≤ 0.001) (versus no pain) were seen to be significantly associated with higher BAI scores. Conclusion The current study observed high prevalence of pain among patients with psychiatric illness that was determined by optimal C.P.s for mild, moderate, and severe pain. Patients diagnosed with anxiety disorders and those with higher BMI were seen to be associated with pain of moderate to severe intensity. Improving the knowledge of correlates and co-morbidities of physical pain would aid in early identification, use of prophylactic strategies, and the intervention techniques to formulate basic guidelines for pain management among psychiatric population.

Transformation of Electronic Health Records and Questionnaire Data to OMOP CDM: A Feasibility Study Using SG_T2DM Dataset.

Background Diabetes mellitus (DM) is an important public health concern in Singapore and places a massive burden on health care spending. Tackling chronic diseases such as DM requires innovative strategies to integrate patients' data from diverse sources and use scientific discovery to inform clinical practice that can help better manage the disease. The Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) was chosen as the framework for integrating data with disparate formats. Objective The study aimed to evaluate the feasibility of converting Singapore based data source, comprising of electronic health records (EHR), cognitive and depression assessment questionnaire data to OMOP CDM standard. Additionally, we also validate whether our OMOP CDM instance is fit for the purpose of research by executing a simple treatment pathways study using Atlas, a graphical user interface tool to conduct analysis on OMOP CDM data as a proof of concept. Methods We used de-identified EHR, cognitive, and depression assessment questionnaires data from a tertiary care hospital in Singapore to convert it to version 5.3.1 of OMOP CDM standard. We evaluate the OMOP CDM conversion by (1) assessing the mapping coverage (that is the percentage of source terms mapped to OMOP CDM standard); (2) local raw dataset versus CDM dataset analysis; and (3) Implementing Harmonized Intrinsic Data Quality Framework using an open-source R package called Data Quality Dashboard. Results The content coverage of OMOP CDM vocabularies is more than 90% for clinical data, but only around 11% for questionnaire data. The comparison of characteristics between source and target data returned consistent results and our transformed data did not pass 38 (1.4%) out of 2,622 quality checks. Conclusion Adoption of OMOP CDM at our site demonstrated that EHR data are feasible for standardization with minimal information loss, whereas challenges remain for standardizing cognitive and depression assessment questionnaire data that requires further work.

Zero Healthcare-Associated COVID-19

Background: The ongoing COVID-19 pandemic tests the healthcare system in many ways. The scarcity of resources poses challenges to infection prevention (IP) practices. We describe our experience in managing such scarcity in our care of COVID-19 patients in the hospital as well as community settings. Methods: The hospital pandemic plan traditionally included only plans for healthcare delivery management within the hospital. However, on March 25, 2020, a decision was made by the Ministry of Health to set up swab isolation (SIFs) and community care facilities (CCFs) to meet the growing demand for isolation beds for migrant workers infected by COVID-19. The CCFs were located in convention halls and resort centers and the SIFs were located in facilities previously functioning as hotels. Mobile medical teams were activated to run clinics at the dormitories housing 200,000 migrant workers. The IP team of an acute- and tertiary-care hospital in Singapore was activated to oversee IP measures at facilities managed by medical teams from the hospital, with the goal of zero healthcare-associated COVID-19 cases among staff. Two IP leaders were set up to oversee the IP program at 8 dormitories, 4 SIFs, and 2 CCFs. In total, 12 IP staff and 15 infection prevention liaison officers (IPLOs) were deployed from 2 acute-care hospitals and 3 specialty centers to conduct training in hand hygiene and the use of personal protective equipment, and to conduct daily audits of compliance to practice guidelines. Education on personal hygiene was also given to patients in these facilities in at least 7 languages. In the SIFs and dormitories, IPLOs were recruited to perform daily audits and feedback to the IP team on issues related to IP at the sites. Results: Since our first COVID-19 patient on January 23, 2020, there has been no report of healthcare-associated COVID-19 within the hospital nor among the medical, administrative, and support service staff working in the external operation facilities. Daily audits showed an average of 99.4% compliance to IP guidelines. Conclusions: IPLOs or IP champions play a significant role in ensuring compliance to IP guidelines. This compliance allows the IP professional to focus on the evaluation of the IP program, managing IP consultations, and planning and implementation of the IP program in nontraditional healthcare settings. The key success factors of the program included the ability to contextualize the planning and implementation of IP programs in various settings, strong leadership support, cohesive teamwork, and effective communication at various levels.Funding: NoDisclosures: None

In-hospital cardiac arrest incidence and outcomes in the era of COVID-19: an observational study in a Singapore hospital

BackgroundCOVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period.MethodsWe conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions.OutcomesThe rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Compared to pre-COVID-19 period, there were more IHCA incidences per 1000 hospital admissions in the COVID-19 period (1.86 vs 1.03; OR, 1.81; 95% CI, 0.78-4.41).ConclusionsThe study observed a trend towards higher incidence of IHCA and lower rate of survival to hospital discharge during COVID-19 pandemic compared to pre-COVID-19 period.

Improving influenza and pneumococcal vaccination uptake among incident peritoneal dialysis patients: a quality improvement initiative.

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations. The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients. A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals. Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively. A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

COVID-19 Pandemic: The Impact of Lockdown Measures on Emergency Department Presentations to a Tertiary Care Hospital in Singapore

Introduction: COVID-19 has affected healthcare systems worldwide. We aim to analyse the impact of the pandemic and ‘lockdown’ measures on the services of a tertiary hospital emergency department (ED) in Singapore. Methods: A retrospective observational study was conducted at the Singapore General Hospital ED, examining visit characteristics, demographics and diagnoses during ‘lockdown’ (7 April to 1 June 2020) comparing it with the same calendar period in 2019. Results: The median number of daily ED visits reduced significantly from 342 (IQR 322-358) to 256 (IQR 246-290) during ‘lockdown’. However, the number of ‘fever’ cases increased by 37 (95% CI 113-132) visits a day, contributing a much higher proportion of total visits during ‘lockdown’ (22% vs 2·7%; p <0·001). ED visits per day for ‘clean’ cases fell by 123 (95% CI 113-132). The proportion of inpatient admissions and length of inpatient stay increased (53% vs 48% and 4 [IQR 2-7] vs 3 [IQR 2-6] days respectively; p <0·001). There were significantly smaller proportions of cases of diarrhea, gastroenteritis, food poisoning, and alcohol intoxication, with no significant change for life-threatening conditions such as acute coronary syndromes and stroke. Conclusion: COVID-19 pandemic and ‘lockdown’ measures have led to decreased ED attendances. Potential reasons include fear of nosocomial infections, but also positive externalities from ‘lockdown’ measures. Surge in ‘fever’ cases and reduction in efficiency is expected. Timely and adequate public messaging, imposition of regulations, ensuring surge capacity and robust resource management are important aspects in managing these changes in characteristics of ED attendances during a pandemic. Funding Information: There was no funding source required for this study. Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: SingHealth Centralized Institutional Review Board approved this study and waived the requirement for participants to provide consent (CIRB Ref: 2020/2684).

Revisiting testicular torsion scores in an Asian healthcare system

Testicular pain is a common presentation amongst young boys. It is important to distinguish between testicular torsion and other testicular pathology as testicular viability is dependent on timely diagnosis and surgical intervention. The aim of this study was to evaluate the utility of the TWIST score in our population. Our second objective was to compare a new testicular torsion score (TT score) developed in a paediatric Asian population, with the TWIST score in risk stratification for testicular torsion. Duration of symptoms and delays after presentation were also correlated with testicular viability. This is a prospective cohort study of children admitted with testicular pain from January 2016 to December 2018 at a tertiary care hospital in Singapore. Relevant findings such as age, nausea/vomiting, testicular swelling/firmness, absence of cremasteric reflex and abnormal lie were collected. Univariate and multivariate logistic regression was performed to identify significant predictive factors of testicular torsion to generate TT score. A total of 315 patients were involved in this study. Mean age of patients was 121.3±44.2 months. There were 43 patients with testicular torsion. No patients with a TT score of ≤1 were found to have testicular torsion. In contrast, 10 patients with a TWIST score of ≤2 were found to have testicular torsion. Of the patients with testicular torsion, 16 had a TWIST score of ≥5 and 22 had a TT score of ≥6. In this study, the area under the curve was 0.87 for the TWIST score and 0.93 for the TT score. In conclusion, the TT score is a reliable score for excluding testicular torsion in an Asian patient population with a sensitivity and negative predictive value of 100% at a cut-off value of ≤1. Both TWIST and TT score performed equally well in early presenters (<6h) Further prospective validation studies are needed to evaluate the utility of the TT score. Delay in presentation to hospital is the most important determinant of outcome.

Epidemiology of Adenovirus Infections and Outcomes of Cidofovir Treatment in Severely Ill Children.

An increase in human adenovirus (HAdV) infections among hospitalized children in Singapore was observed since 2013. Young age (<2 years) and significant comorbidities have been associated with severe HAdV infections which can result in significant morbidity and mortality. Cidofovir (CDV) has been used to treat severe HAdV infections despite limited data and efficacy. This is a retrospective, observational review of infants and children 1 month to 17 years of age with laboratory-confirmed severe HAdV infection, admitted to a pediatric tertiary care hospital in Singapore between January 2013 and September 2017. Severe infection was defined as requiring intensive care unit or high dependency care at any point during hospital admission. Clinical characteristics, potential risk factors for mortality, as well as the outcome of cases treated with CDV were examined. A total of 1167 children were admitted for HAdV infection, of which 85 (7.3%) were severe. For severe infections, the median age was 1.5 years (interquartile range: 0.72-3.2 years). The majority had comorbidities (69.4%) and presented with pneumonia (32.9%). Genotypes HAdV-7 (29.4%) and HAdV-3 (27.0%) were the most common HAdV genotypes identified. Thirteen (15.3%) patients died. Patients who died had a higher proportion of existing neurologic comorbidity (46.2% vs. 13.9%; P = 0.014) and presentation with pneumonia (69.2% vs. 26.4%; P = 0.008) compared with survivors. Patients who presented with pneumonia had a higher risk of 30-day mortality (odds ratio 4.3, 95% confidence interval: 1.0-28.6; P < 0.05). CDV was administered to 17 (20%) children for mainly viremia (47.1%) and/or pneumonia (41.2%). Mortality rate was 41.2% for severe HAdV cases treated with CDV. A significant proportion of patients who died when compared with recovered patients presented with pneumonia (6 of 7, 85.7% vs 1 of 10, 10%; P = 0.004). All 8 patients who had viremia received CDV and survived. Mortality can be high in pediatric patients with severe HAdV infections. HAdV-7 and HAdV-3 were the most common genotypes identified in our cohort with severe HAdV infection. Pneumonia is a potential risk factor for mortality in severe HAdV infections in our cohort. Early CDV administration may be considered in patients with severe HAdV infection and existing comorbidities but more studies are required.

Respiratory surveillance wards as a strategy to reduce nosocomial transmission of COVID-19 through early detection: The experience of a tertiary-care hospital in Singapore.

Patients with COVID-19 may present with respiratory syndromes indistinguishable from those caused by common viruses. Early isolation and containment is challenging. Although screening all patients with respiratory symptoms for COVID-19 has been recommended, the practicality of such an effort has yet to be assessed. Over a 6-week period during a SARS-CoV-2 outbreak, our institution introduced a "respiratory surveillance ward" (RSW) to segregate all patients with respiratory symptoms in designated areas, where appropriate personal protective equipment (PPE) could be utilized until SARS-CoV-2 testing was done. Patients could be transferred when SARS-CoV-2 tests were negative on 2 consecutive occasions, 24 hours apart. Over the study period, 1,178 patients were admitted to the RSWs. The mean length-of-stay (LOS) was 1.89 days (SD, 1.23). Among confirmed cases of pneumonia admitted to the RSW, 5 of 310 patients (1.61%) tested positive for SARS-CoV-2. This finding was comparable to the pickup rate from our isolation ward. In total, 126 HCWs were potentially exposed to these cases; however, only 3 (2.38%) required quarantine because most used appropriate PPE. In addition, 13 inpatients overlapped with the index cases during their stay in the RSW; of these 13 exposed inpatients, 1 patient subsequently developed COVID-19 after exposure. No patient-HCW transmission was detected despite intensive surveillance. Our institution successfully utilized the strategy of an RSW over a 6-week period to contain a cluster of COVID-19 cases and to prevent patient-HCW transmission. However, this method was resource-intensive in terms of testing and bed capacity.

Who listens and who doesn’t? Factors associated with adherence to antibiotic stewardship intervention in a Singaporean tertiary hospital

IntroductionAntibiotic stewardship programmes (ASPs) can improve patient outcomes by prospective audit and feedback with interventions. However, adherence to ASP interventions is not mandatory. Identifying factors associated with improved adherence may help to enhance ASP recommendations and activities. MethodsA retrospective cohort study was conducted, comprising all ASP interventions performed as part of the prospective audit and feedback strategy in our institution (an acute tertiary-care hospital in Singapore) from January 2016 to July 2018. Adherence to ASP intervention was ascertained based on documented compliance with the recommended interventions within 48h. Factors associated with adherence to ASP interventions, such as patient demographics, clinical condition, type of infection, and characteristics of ASP interventions were identified using the χ2 test for categorical variables. On multivariate analysis, factors independently associated with adherence to ASP intervention were identified using logistic regression. ResultsAdherence to ASP intervention was 81.9% (5758/7028). On univariate and multivariate analysis, interventions coupled with direct communication via phone call (adjusted odds ratio [aOR] 1.61, 95% CI 1.23–2.08) were associated with higher odds of adherence, whereas admission to a surgical unit, intervention involving carbapenem use, and recommendation to de-escalate or discontinue antibiotics were associated with lower odds of adherence to ASP interventions. ConclusionAlthough adherence rates to ASP interventions were relatively high, interventions made to the surgical unit and recommendations related to carbapenem use were not so well received. Interventions communicated verbally via phone call were well received, highlighting the need for a close working relationship between ASP teams and hospital physicians.