Tertiary Hospital In Singapore Research Articles

Resuming elective surgery after COVID-19: A simulation modelling framework for guiding the phased opening of operating rooms

ObjectiveTo develop a 2-stage discrete events simulation (DES) based framework for the evaluation of elective surgery cancellation strategies and resumption scenarios across multiple operational outcomes. Materials and MethodsStudy data was derived from the data warehouse and domain knowledge on the operational process of the largest tertiary hospital in Singapore. 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 were extracted for the study. A clustering approach was used in stage 1 of the modelling framework to develop the groups of surgeries that followed distinctive postponement patterns. These clusters were then used as inputs for stage 2 where the DES model was used to evaluate alternative phased resumption strategies considering the outcomes of OR utilization, waiting times to surgeries and the time to clear the backlogs. ResultsThe tool enabled us to understand the elective postponement patterns during the COVID-19 partial lockdown period, and evaluate the best phased resumption strategy. Differences in the performance measures were evaluated based on 95% confidence intervals. The results indicate that two of the gradual phased resumption strategies provided lower peak OR and bed utilizations but required a longer time to return to BAU levels. Minimum peak bed demands could also be reduced by approximately 14 beds daily with the gradual resumption strategy, whilst the maximum peak bed demands by approximately 8.2 beds. Peak OR utilization could be reduced to 92% for gradual resumption as compared to a minimum peak of 94.2% with the full resumption strategy. ConclusionsThe 2-stage modelling framework coupled with a user-friendly visualization interface were key enablers for understanding the elective surgery postponement patterns during a partial lockdown phase. The DES model enabled the identification and evaluation of optimal phased resumption policies across multiple important operational outcome measures. Lay abstractDuring the height of the COVID-19 pandemic, most healthcare systems suspended their non-urgent elective surgery services. This strategy was undertaken as a means to expand surge capacity, through the preservation of structural resources (such as operating theaters, ICU beds, and ventilators), consumables (such as personal protective equipment and medications), and critical healthcare manpower. As a result, some patients had less-essential surgeries postponed due to the pandemic. As the first wave of the pandemic waned, there was an urgent need to quickly develop optimal strategies for the resumption of these surgeries. We developed a 2-stage discrete events simulation (DES) framework based on 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 captured in the Singapore General Hospital (SGH) enterprise data warehouse. The outcomes evaluated were OR utilization, waiting times to surgeries and time to clear the backlogs. A user-friendly visualization interface was developed to enable decision makers to determine the most promising surgery resumption strategy across these outcomes. Hospitals globally can make use of the modelling framework to adapt to their own surgical systems to evaluate strategies for postponement and resumption of elective surgeries.

Trends of chronic illness in emergency department admissions among elderly adults in a tertiary hospital over ten years

BackgroundThis study aimed to determine to what extent an aging population and shift to chronic illness has contributed to emergency admissions at a tertiary care hospital over ten years.MethodsThis was a retrospective observational study performed using a database of all emergency admissions from the Emergency Department (ED) at a single tertiary hospital in Singapore during a ten-year period (January 1st, 2008 to December 31st, 2017). Emergency admissions were defined as ED visits with inpatient admission as the disposition. This study analyzed the trends of demographics, pre-existing comorbidities, chronic conditions or ambulatory care sensitive conditions (ACSC) of all patients who underwent emergency admissions in Singapore General Hospital.ResultsA total of 446,484 emergency records were included. For elderly patients, the proportions of them had pre-existing multimorbidity at the time of undergoing emergency admissions were found to be lower at the end the 10-year study period relative to the beginning of the study period. The proportions of emergency admissions whose ED primary diagnoses were categorized as chronic conditions and certain chronic ACSC including chronic obstructive pulmonary disease, congestive heart failure, diabetes complications, and epilepsy also decreased for elderly patients over the 10-year study period.ConclusionsIn Singapore, despite a rapidly aging population, there have been surprisingly lower proportions of chronic conditions, pre-existing comorbidities, and chronic ACSC among the elderly emergency admissions. This is possibly consistent with an overall improved management of the chronic conditions among the elderly population. Future studies should include similar studies at the national level and comparison with other healthcare settings in different countries.

Teaching Communication Micro-Skills to Cardiologists Managing Seriously Ill Patients in Asia: Challenges Encountered Amidst the COVID-19 Pandemic and Future Perspectives

BackgroundPatients with advanced cardiac conditions value effective symptom control and empathic communication with their doctors. However, studies have shown that empathic communication with seriously ill patients does not occur adequately in cardiology. Therefore, we piloted a program for teaching communication skills in a bite-sized manner. The primary aim of the research was to understand the feasibility and acceptability of the training program and to perform a preliminary evaluation of its efficacy.MethodologyClinicians were recruited from the cardiology unit of a tertiary hospital in Singapore. Patients were also recruited for the audio recording of clinic consults. Recruited patients had to have a chronic cardiac condition and be deemed at risk of dying within one year. We utilized a pre-post intervention design. Prior to the educational intervention, clinicians were asked to audio record a single clinic consult at baseline. They were then asked to participate in a training program that consisted of video-annotated presentations and role-play scenarios. Subsequently, the audio recordings of their clinic consults with seriously ill patients were recorded. The audio recordings were evaluated by trainers and used for feedback with clinicians. Data on the completion rate of the training program were collected. In addition, changes in the clinicians’ self-rated communication skills and views on the acceptability and relevance of the training program were collected.ResultsOverall, five of the six clinicians (83.3%) completed all sessions in the program. One clinician only completed four out of the five sessions in the program. Clinicians deemed the program acceptable and relevant and found audio recordings to be useful for reflective learning. There was an improvement in the clinicians’ self-assessed competency. However, the planned number of audio recordings could not be completed due to the coronavirus disease 2019 pandemic.ConclusionsThe pilot training program was acceptable and relevant for the participants. However, it will require adaptation to allow it to be transferrable and scalable to all settings, especially in situations that limit prolonged face-to-face contact.

Experience of Patients in a Consult Model versus an Integrated Palliative Care and Medical Oncology Co-Rounding Model: A Qualitative Study.

Background: Research on different models of palliative care should include evaluation of the patients' experience of care. Objectives: To understand the patients' experience regarding care received in a consult model versus an integrated palliative care and medical oncology co-rounding model during a hospital admission. Design: Qualitative study using thematic analysis. Setting/Subjects: Seventeen patients with stage 4 solid tumor admitted to a tertiary hospital in Singapore. Results: Although experiences of care during the hospital stay were similar in both models, patients in the integrated model were able to better articulate the benefits of palliative care involvement alongside oncologists-to facilitate better communication and a more holistic understanding of the clinical context, with a view to effectively addressing the patient's needs. Conclusions: An integrated co-rounding model may possibly smoothen the transition for advanced cancer patients to palliative care, and could perhaps be considered for implementation to foster reach of palliative care services and improve patient experience.

Clinical Outcomes of Adults and Young Adults (AYA) with Acute Lymphoblastic Leukemia (ALL): A Multicenter Analysis of Pediatric-Inspired Protocol (MASPORE) Vs Hyper-CVAD in Singapore

Introduction:In acute lymphoblastic leukemia (ALL) adolescents and young adults (AYA), there are benefits when using pediatric over adult treatment regimes. There is improved overall survival (OS), progression free survival (PFS) and reduced need for hematopoietic stem cell transplantation; all while having an acceptable toxicity profile. Yet, studies supporting this were largely performed in a western population (e.g., United Kingdom and United States) and thus may have had limited representation of the Asian population. Whether these results are generalizable and applicable to an Asian population is in question. MASPORE, a locally designed pediatric regiment based on BFM regimen, which has been used successfully in Singapore and Malaysia's AYA cohort since 2007. MASPORE protocol utilized PCR-based minimal residual disease (MRD) marker to risk stratify patients according to disease severity and used a 3- or 4-drug induction regimen depending on intermediate or high-risk stratification (L-asparaginase, Vincristine, Dexamethasone +/- daunorubicin). In contrast HyperCVAD does not use MRD to stratify or guide management. In this retrospective study performed in Singapore, we aim to demonstrate that MASPORE is an effective treatment option for AYA ALL in Asian population.Methods:Patient registries (IRB approved) spanning from January 2005 to June 2021 from three tertiary hospitals in Singapore were reviewed. ALL patients who were AYA, defined as less than 40 years of age, treated during this time were included and analyzed. Patients were treated with either the pediatric protocol MASPORE or with the adult protocol HyperCVAD. Patients who are Philadelphia positive were excluded from the MASPORE arm up to 2020. Patients' demographics, functional status, risk profile, adverse events, as well as the hematological response and transplant status were collected and analyzed with Pearson chi-square test. Kaplan Meier curve analysis were performed for OS and PFS with SPSS software.Results:In this retrospective study, 116 patients were analyzed. Among these patients 29 (25%) received MASPORE and 87 (75%) received HyperCVAD. The median age was 23 (range 18-40) for MASPORE arm vs 28 years (range 15-40) for the HCVAD arm. median follow-up time was 4.5 vs 10.8 years. Both groups were similar in gender, race, ECOG status, and ALL risk status at diagnosis. Likewise, both arms did not have differences in starting hematological parameters: hemoglobin, total white blood cell count, platelet count, absolute neutrophil count, and bone marrow blast percentages. Median time from diagnosis to treatment was 3 and 4 days for MASPORE and HyperCVAD arms respectively. There were increased adverse rates for patients in the MASPORE arm. They had more (13.8 vs 0.0%, p < 0.001) of which 75% of the pancreatitis were CTCAE grade 3/4, avascular necrosis (13.8 vs 2.2%, p = 0.016), cerebral venous thrombosis (13.8 vs 1.1%, p = 0.004) and other thrombosis (27.6 vs 5.7%, p = 0.004). For the MASPORE and HyperCVAD arms there was one induction death, one from sepsis and the other from pneumonia . Both arms managed to achieve complete response (CR) with equivalent rates (82.5 vs 80.5%, p = 0.752). However, there was less relapsed or refractory disease in those treated with MASPORE (10.3 vs 44.8%, p < 0.001). The 5- OS was better in the MASPORE versus the HyperCVAD arm (4.4 vs 3.7 years; p = 0.049). Likewise, the 5-year PFS was superior in the MASPORE arm (4.2 vs 3.2 years, p = 0.034). Furthermore, a smaller proportion of patients required consolidative stem cell transplant (13.8 vs 49.4%, p < 0.001).Conclusion:The pediatric-inspired protocol MASPORE achieved similar CR rates with OS and PFS benefit, reduced relapse rates, and less need for consolidative stem cell transplant. MASPORE serves as a viable treatment option when treating AYA patients with ALL. Larger prospective studies are needed to further explore its use. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The early stages of caregiving: A qualitative study into the caregiving experiences of Asian family caregivers of persons with newly-diagnosed dementia

In Asian societies, the responsibility of caring for persons with dementia often falls upon an immediate family member. However, little attention has been paid to the early stages of caregiving, as well as their transition into a more experienced caregiver. Thus, a qualitative descriptive study involving a purposive sample of 11 main family caregivers of a person with newly diagnosed dementia was recruited from a tertiary hospital in Singapore. Three themes emerged from the data analysis: (1) Suspicions to seeking confirmation of dementia, (2) Grappling with dementia diagnosis, and (3) Making adjustments for the future. Areas of needs and support identified during the early caregiving journey suggest the need for caregivers to be prepared for the practical and emotional challenges. Unique to the Asian culture, our findings put forth the advocacy of engaging persons with dementia in the discussions of their long-term care and options.

Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization.

As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors. This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS. A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57years (range 60-105) with an average LOS 13.64 ± 10.0days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029). Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.

Burden of informal care in stroke survivors and its determinants: a prospective observational study in an Asian setting

BackgroundInformal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor’s outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore.MethodsStroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients’ likelihood of requiring informal care, hours of informal care required, and informal caregivers’ Zarit’s Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients’ and informal caregivers’ demographic characteristics, arrangement of informal care, and patients’ health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities.ResultsThree hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit’s Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden.ConclusionsInformal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden.

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS). This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI. A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10µmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63-11.70; P < 0.001). Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

Investigating the Role of Low-FODMAP Diet in Improving Gastrointestinal Symptoms in Irritable Bowel Syndrome

Background A low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) appeared to improve gastrointestinal symptoms in patients with Irritable Bowel Syndrome (IBS). However, evidence of its efficacy in Asia remains scarce. Objectives This study aims to investigate the clinical effectiveness of LFD intervention among Asian IBS patients and barriers to its adherence. Methods Patients with IBS who were instructed to follow LFD by dietitians at a tertiary hospital in Singapore between July 2013 and December 2014 were retrospectively reviewed. Severity scores of 19 gastrointestinal symptoms were recorded using an 11-point rating scale (0 = “no symptoms,” 10 = “extremely severe”) pre- and post-LFD intervention. Adherence to LFD was assessed based on patients’ diet history and a high-FODMAP food checklist. Results Eighty-two patients with a median follow-up of 5.8 weeks were investigated. The LFD adherence rate was 61.0% ( n = 50). Overall, statistically significant improvement was observed in 14 of 19 gastrointestinal symptoms (median difference = −2.0 to −0.5, p &lt; .05). The proportion of patients who had improvement in 10 individual symptoms (defined as ≥1 point reduction in symptom severity rating) was significantly higher in LFD-adherent patients (67.5%–82.4%) than that of the non-adherent group (27.8%–55.0%). Reasons reported for non-adherence included “limited availability of low-FODMAP alternatives” ( n = 9), “limited understanding of LFD” ( n = 7), and “perceived lack of benefit” ( n = 4). Conclusions LFD intervention improved gastrointestinal symptoms in a cohort of Asian IBS patients. Limited access to low-FODMAP alternatives was the main barrier to adherence.

Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest

AimDispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Despite the use of protocols, dispatchers may falsely recognise some cases to be in cardiac arrest. Hence, this study aimed to find the incidence of DA-CPR initiated for non-OHCA cases, its characteristics and clinical outcomes in the Singapore population. MethodsThis was a multi-centre, observational study of all dispatcher-recognised cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was obtained from the Pan-Asian Resuscitation Outcomes Study cohort. Audio review of dispatch calls from the national emergency ambulance service were conducted and information about patients’ clinical outcomes were prospectively collected from health records. Univariate analysis was performed to determine factors associated with in-hospital mortality among non-OHCA patients who received DA-CPR. ResultsOf the 821 patients recognised as having OHCA 328 (40.0%) were not in cardiac arrest and 173 (52.7%) of these received DA-CPR. No complications from chest compressions were found from hospital records. The top diagnoses of non-OHCA patients were cerebrovascular accidents (CVA), syncope and infection. Only final diagnoses of CVA (aOR 20.68), infection (aOR 17.34) and myocardial infarction (aOR 32.19) were significantly associated with in-hospital mortality. ConclusionIn this study, chest compressions initiated on patients not in cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Physical activity in patients with axial spondyloarthritis in a multi-ethnic south-east Asian country

BackgroundPatients with axial spondyloarthritis (axSpA) may experience spinal stiffness and pain, leading to reduced physical function and quality of life. Despite the benefits of physical activity (PA) and exercise, previous studies have demonstrated lower levels of PA among patients with axSpA. This study aims to examine the patterns of PA among patients with axSpA compared to the general population in a multi-ethnic Asian country.MethodsThis was a cross-sectional study conducted between May 2016 and Jan 2017. Consecutive patients with axSpA were recruited at an outpatient rheumatology clinic at Singapore General Hospital, the largest tertiary hospital in Singapore. Controls were based on a previous cross-sectional study. PA was assessed using the Global Physical Activity Questionnaire (GPAQ).ResultsSeventy-four patients with axSpA were recruited and compared with 2679 controls. Lower proportion of patients with axSpA met the WHO recommendations for PA (axSpA = 77.0%, controls = 89.7%, p < 0.001). More patients with axSpA had high level of sedentary activity compared to controls (axSpA = 56.8%, controls = 36.1%, p < 0.001). Levels of PA did not differ between patients with inactive versus active axSpA disease (p = 0.91).ConclusionsProportion of patients with axSpA meeting the WHO recommendations for PA differed significantly from the general population, and level of PA did not differ between patients with active and inactive axSpA disease. Higher levels of sedentary activity were seen in patient with axSpA compared to the general population, highlighting the need for interventions to promote PA among patients with axSpA.

Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department

Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70–0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.

Development and Assessment of an Interpretable Machine Learning Triage Tool for Estimating Mortality After Emergency Admissions

Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations. To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores. This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021. Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis. The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores. In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.

Perceptions of Stakeholders Toward "Hospital at Home" Program in Singapore: A Descriptive Qualitative Study.

Hospital at Home (HaH) programs have been shown to improve quality of care and patient satisfaction, and reduce bed occupancy rate in hospitals. Despite the prevalence of HaH in Western countries, studies in Asia are limited and the perception of HaH remains underexplored in Asian context. Understanding the perceptions of stakeholders is vital before implementing HaH in any new settings. Thus, the aim of this study is to explore the perceptions of referring physicians, care providers, patients, and caregivers on HaH programs in a multiracial country such as in Singapore. This study used a descriptive qualitative design. Participants from 2 tertiary hospitals in Singapore, including 13 referring physicians, 10 care providers, 15 patients, and 3 caregivers, were interviewed between June 2020 and September 2020. Data were analyzed using inductive thematic analysis. The overarching theme titled "The stakeholders' perception on HaH" was pillared by 4 main themes: (1) patients suitable for HaH; (2) perceived advantages and benefits of HaH; (3) perceived risks, anxiety, and concerns about HaH; and (4) potential enablers of HaH. Overall, the findings reported that most of the stakeholders embraced HaH. Timely medical interventions and support from care providers were reportedly important factors to maintain patient safety and quality of care. The importance of having adequate resources and sound financing mechanisms to develop a successful HaH program was also highlighted. This study offered insights into HaH from the perspectives of stakeholders in Singapore and facilitate the planning of future HaH pilot programs in multiracial Singapore and other Asian countries.

A study of 3013 cases of hepatocellular carcinoma: Etiology and therapy before and during the current decade.

Background and AimHepatocellular carcinoma (HCC) is a significant global problem. With advances in HCC diagnosis and therapy, our hypothesis is that there are significant differences in the clinical characteristics and treatment of HCC over the years.MethodsPatients with HCC between 1980 and 2018 from three major tertiary hospitals in Singapore were enrolled into a Research Electronic Data Capture database. Clinical characteristics and treatment of HCC were compared between those diagnosed before 2008 (cohort A) and during the current decade (ie from 2008 onwards) (cohort B).ResultsThere were 3013 patients. Mean age of HCC diagnosis was significantly older in cohort B (68.6 vs 61.2 years, P < 0.001). The most common etiology remained as chronic hepatitis B infection but the proportion due to hepatitis B was significantly lower in cohort B (46.6% vs 57.2%, P < 0.0001). The prevalence of cryptogenic/non‐alcoholic steatohepatitis was significantly higher in cohort B than cohort A (27.1% vs 18.6%, P < 0.0001). More patients received curative therapy in cohort B (43.7% vs 27.1%, P < 0.0001.ConclusionIn this largest collection of HCC patients in Singapore, patients are diagnosed with HCC at an older age and cryptogenic/non‐alcoholic steatohepatitis is becoming more important as an etiology of HCC in the current decade. More patients also received curative therapy in the current decade.

Ward-level factors associated with methicillin-resistant Staphylococcus aureus acquisition-an electronic medical records study in Singapore.

Methicillin-Resistant Staphylococcus aureus (MRSA) is endemic in hospitals worldwide. Intrahospital transfers may impact MRSA acquisition risk experienced by patients. In this study, we investigated ward characteristics and connectivity that are associated with MRSA acquisition. We analysed electronic medical records on patient transfers and MRSA screening of in-patients at an acute-care tertiary hospital in Singapore to investigate whether ward characteristics and connectivity within a network of in-patient wards were associated with MRSA acquisition rates over a period of four years. Most patient transfers concentrated in a stable core network of wards. Factors associated with increased rate of MRSA acquisition were MRSA prevalence among patients transferred from other wards (rate ratio (RR): 7.74 [95% confidence interval (CI): 3.88, 15.44], additional 5 percentage point), critical care ward (RR: 1.72 [95% CI: 1.09, 2.70]) and presence of MRSA cohorting beds (RR: 1.39 [95% CI: 1.03, 1.90]. Oncology ward (RR: 0.66 [95% CI: 0.46, 0.94]) (compared to medical ward), and median length of stay (RR: 0.70 [95% CI: 0.55, 0.90], additional 1.5 days) were associated with lower acquisition rates. In addition, we found evidence of interaction between MRSA prevalence among patients transferred from other wards and weighted in-degree although the latter was not associated with MRSA acquisition after controlling for confounders. Wards with higher MRSA prevalence among patients transferred from other wards were more likely to have higher MRSA acquisition rate. Its effect further increased in wards receiving greater number of patients. In addition, critical care ward, presence of MRSA cohorting beds, ward specialty, and median length of stay were associated with MRSA acquisition.

A descriptive qualitative study exploring the experiences of fathers with partners suffering from maternal perinatal depression

ObjectiveThe onset of maternal perinatal depression poses many challenges for fathers, yet in Singapore and Asia, the topic remains largely unexplored. This study aimed to gain insight into the experiences of fathers whose partners suffer from perinatal depression in the Asian milieu. DesignA descriptive qualitative study design was adopted. Purposive and snowball sampling methods were used to recruit participants. Semi-structured, face-to-face interviews were conducted individually with participants to collect data, which were analysed using thematic analysis. Setting and participantsTwelve fathers were recruited for the study. Eleven were from a perinatal mental health service in a tertiary hospital in Singapore, while 1 father was recruited via snowball sampling. FindingsFive themes describing the fathers’ journey through their partners’ perinatal depression emerged from the analysis. The themes are: (1) feeling their world collapse; (2) struggling with the depression; (3) enduring the emotional toll; (4) coping with the situation; and (5) emerging from the other side. Key conclusionsThe findings of this study highlighted the struggles, coping methods, and support needs of fathers whose partners suffer from perinatal depression. Fathers were often unable to identify perinatal depression in their partners. Notably, they testified to the need to tolerate verbal and sometimes violent outbursts from their partners, and requested for more available information, resources, and peer support groups. Implications for practiceThe findings underscore a need for pre-emptive education on maternal perinatal depression and more accessible resources. Healthcare professionals should assess fathers’ emotional responses to parenthood and their partners’ depression.

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

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

A retrospective review of serious infections in febrile infants 0–90 days old

Background: Fever without source in infants is a common clinical problem that accounts for many ambulatory care visits and hospitalisations. Currently, there is no reliable method of identifying those at risk of serious infection (SI). Objective: The goal of this study was to determine the incidence and identify the predictors of SI in febrile infants who presented to the emergency department (ED). Methods: This was a single-centre retrospective cohort study of children presenting to a Singapore tertiary hospital paediatric unit between 1 July 2018 and 31 December 2018. Children were included if they were aged 0–90 days and presented to the ED with a fever. SI was defined as urinary tract infection (UTI), sepsis, bacteraemia, meningitis (viral and bacterial), enterocolitis, osteomyelitis, abscess or pneumonia. Results: Of the 659 infants, 161 (24.4%) were diagnosed with SI. Meningitis (49.7%) was the most common SI, followed by UTI (45.3%), enterocolitis (5.6%), sepsis (3.1%) and bacteraemia (2.5%). Factors significantly associated with SI were aged 29–60 days, male sex, Severity Index Score (SIS) &lt;10, absolute neutrophil counts &gt;10×109/L, C-reactive protein (CRP) &gt;20 mg/L and procalcitonin &gt;0.5 ng/mL. Multivariate analysis entering all these items retained only male sex, SIS &lt;10 and CRP &gt;20. Conclusion: Among hospitalised infants aged 0–90 days, the incidence of SI was 24.4%, and invasive bacterial infection was 0.6%. Meningitis was the most common SI followed by UTI. SIS and CRP can be used to predict SI in infants &lt;90 days old.