Health-seeking behaviour of foreign workers in Singapore: Insights from emergency department visits

INTRODUCTION@#Foreign workers (FWs) on work permit face unique health challenges and potential barriers to healthcare. We aimed to examine the epidemiology, attendance patterns, disposition, and adherence to follow-up, by FWs on work permit to two emergency departments (EDs) in Singapore.@*METHODS@#In this retrospective observational study, we included consecutive FWs on work permit who registered at the EDs of two public restructured hospitals from 1 May 2016 to 31 October 2016. Data obtained from electronic medical records included patient demographics, triage acuity, disposition, ED diagnoses and bill information.@*RESULTS@#There were 6,429 individual FWs on work permit who contributed to 7,157 ED visits over the 6-month study period, with male predominance (72.7%, 4672/6429), and median age of 31 (interquartile range 26 to 38) years. A high proportion of these FWs were triaged to low-acuity status compared to the general ED population (66.9% versus 45.9%, @*CONCLUSION@#In Singapore, the EDs of public restructured hospitals provide healthcare safety nets to FWs on work permit. These workers made more low-acuity visits compared to the general population during the study period and may face potential barriers to admission and follow-up.

Effect of Using an Audiovisual CPR Feedback Device on Chest Compression Rate and Depth

<p><b>INTRODUCTION</b>The aim of the study is to investigate the effect of using Automated External Defibrillator (AED) audiovisual feedback on the quality of cardiopulmonary resuscitation (CPR) in a manikin training setting.</p><p><b>MATERIALS AND METHODS</b>Five cycles of 30 chest compressions were performed on a manikin without CPR prompts. After an interval of at least 5 minutes, the participants performed another 5 cycles with the use of real time audiovisual feedback via the ZOLL E-Series defibrillator. Performance data were obtained and analysed.</p><p><b>RESULTS</b>A total of 209 dialysis centre staff participated in the study. Using a feedback system resulted in a statistically significant improvement from 39.57% to 46.94% (P=0.009) of the participants being within the target compression depth of 4 cm to 5 cm and a reduction in those below target from 16.45% to 11.05% (P=0.004). The use of feedback also produced a significant improvement in achieving the target for rate of chest compression (90 to 110 compressions per minute) from 41.27% to 53.49%; (P<0.001). The mean depth of chest compressions was 4.85 cm (SD=0.79) without audiovisual feedback and 4.91 (SD=0.69) with feedback. For rate of chest compressions, it was 104.89 (SD=13.74) vs 101.65 (SD=10.21) respectively. The mean depth of chest compression was less in males than in females (4.61 cm vs 4.93 cm, P=0.011), and this trend was reversed with the use of feedback.</p><p><b>CONCLUSION</b>In conclusion, the use of feedback devices helps to improve the quality of CPR during training. However more studies involving cardiac arrest patients requiring CPR need to be done to determine if these devices improve survival.</p>

Effect of location of out-of-hospital cardiac arrest on survival outcomes

<p><b>INTRODUCTION</b>This study aims to study how the effect of the location of patient collapses from cardiac arrest, in the residential and non-residential areas within Singapore, relates to certain survival outcomes.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study of data were done from the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Out-of- hospital cardiac arrest (OHCA) data from October 2001 to October 2004 (CARE) were used. All patients with OHCA as confirmed by the absence of a pulse, unresponsiveness and apnoea were included. All events had occurred in Singapore. Analysis was performed and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI).</p><p><b>RESULTS</b>A total of 2375 cases were used for this analysis. Outcomes for OHCA in residential areas were poorer than in non-residential areas-1638 (68.9%) patients collapsed in residential areas, and 14 (0.9%) survived to discharge. This was significantly less than the 2.7% of patients who survived after collapsing in a non-residential area (OR 0.31 [0.16 - 0.62]). Multivariate logistic regression analysis showed that location alone had no independent effect on survival (adjusted OR 1.13 [0.32 - 4.05]); instead, underlying factors such as bystander CPR (OR 3.67 [1.13 - 11.97]) and initial shockable rhythms (OR 6.78 [1.95 - 23.53]) gave rise to better outcomes.</p><p><b>CONCLUSION</b>Efforts to improve survival from OHCA in residential areas should include increasing CPR by family members, and reducing ambulance response times.</p>

Recognition and treatment of out-of-hospital cardiac arrests by non-emergency ambulance services in Singapore

<p><b>INTRODUCTION</b>Prompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) and defibrillation is necessary for good outcomes from out-of-hospital cardiac arrest (OHCA). This study aims to describe the recognition and treatment of OHCA in patients conveyed by non-emergency ambulance services (EAS) in Singapore.</p><p><b>MATERIALS AND METHODS</b>This is a multi-centre, retrospective chart review, of cases presenting to public emergency departments (EDs), conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. The study was from October 2002 to August 2009. The following variables were examined: ability to recognise cardiac arrest, whether CPR was carried out by the ambulance crew and whether an automated external defibrillator (AED) was applied.</p><p><b>RESULTS</b>Eighty-six patients were conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. Mean age was 63 years (SD 21.8), 70.9% were males. A total of 53.5% of arrests occurred in the ambulance while 70.9% were found to be asystolic upon ED arrival. Seven patients had a known terminal illness. Survival to discharge was 3.5%. Cardiac arrest went unrecognised by the ambulance crew in 38 patients (44.2%). CPR was performed in 35 patients (40.7%) of the 86 patients and AED was applied in only 10 patients (11.6%).</p><p><b>CONCLUSION</b>We found inadequate recognition and delayed initiation of treatment for OHCA. Possible reasons include a lack of training in patient monitoring and detection of cardiac arrest, lack of CPR training, lack of confidence in performing CPR, lack of AEDs on ambulances and lack of training in their use.</p>

An eight year review of exercise-related cardiac arrests

<p><b>INTRODUCTION</b>Exercise-related cardiac arrest is uncommon, however it is devastating when it occurs in otherwise healthy adults. This study aims to identify the characteristics of exercise-related cardiac arrest in the study population and estimate the overall survival rate.</p><p><b>MATERIALS AND METHODS</b>This is a retrospective observational study of exercise-related cardiac arrest in Singapore. Patients with exercise-related out of hospital cardiac arrest (OHCA) were selected from the Cardiac Arrest and Resuscitation Epidemiology (CARE) database, which is a prospective cardiac arrest registry, derived from ambulance records, emergency department and hospital discharge records. Patient characteristics, cardiac arrest circumstances and outcomes were studied.</p><p><b>RESULTS</b>Fifty-fi ve cases of exercise-related cardiac arrests were identified from December 2001 to January 2008. Mean age was 50.9 years with a male predominance of 96.4%. Eighty percent of the exercise-related cardiac arrests were witnessed, however only 58.2% of the patients received bystander cardiopulmonary resuscitation (CPR). The fi rst presenting rhythm was ventricular fibrillation (VF) in 40% of the patients, followed by asystole (38.2%). Of 96.2% of the patients who died from cardiac causes, coronary artery disease was the main etiology for 54%. The 30-day survival rate was 5.5%.</p><p><b>CONCLUSION</b>We found that exercise-related cardiac arrest causes significant mortality in our community. Increased CPR training among the public, easy access to defibrillators and faster emergency medical service (EMS) response time could improve the outcome of exercise-related cardiac arrests. A comprehensive pre-participation screening for competitive exercises should be outlined for primary prevention of exercise-related cardiac arrest. A better reporting system for exercise-related cardiac arrest is needed.</p>

An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device

<p><b>INTRODUCTION</b>Intraosseous access is an alternative to conventional intravenous access when access is difficult or impossible in the adult population. The EZ-IO is a novel intraosseous access device designed for use in adults, utilising a powered driver.</p><p><b>MATERIALS AND METHODS</b>A prospective, observational study involving a convenience sample of 25 medical students, physicians and nursing staff recruited as study subjects to secure intraosseous access using the EZIO powered drill device, on a bone model.</p><p><b>RESULTS</b>Twenty-three (92%) of the 25 study subjects required only 1 attempt at placing the EZ-IO. There were 24 (96%) successful placements of the EZ-IO. The average time taken to place the EZ-IO was 13.9 seconds. Twenty (87%) of 23 participants reported easier placement with the EZ-IO than an intravenous cannula. The average time taken for the physicians, nursing staff and medical students was 3.71 (+/- SD 1.70) seconds, 7.88 (+/- SD 4.02) seconds and 33.7 (24.5), respectively. Overall mean difficulty of insertion score (VAS) was 3.1 (+/- SD 1.9).</p><p><b>CONCLUSION</b>The intraosseous access device evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential for use in the Emergency Department.</p>

Geographic-time distribution of ambulance calls in Singapore: utility of geographic information system in ambulance deployment (CARE 3)

<p><b>INTRODUCTION</b>Pre-hospital ambulance calls are not random events, but occur in patterns and trends that are related to movement patterns of people, as well as the geographical epidemiology of the population. This study describes the geographic-time epidemiology of ambulance calls in a large urban city and conducts a time demand analysis. This will facilitate a Systems Status Plan for the deployment of ambulances based on the most cost effective deployment strategy.</p><p><b>MATERIALS AND METHODS</b>An observational prospective study looking at the geographic-time epidemiology of all ambulance calls in Singapore. Locations of ambulance calls were spot mapped using Geographic Information Systems (GIS) technology. Ambulance response times were mapped and a demand analysis conducted by postal districts.</p><p><b>RESULTS</b>Between 1 January 2006 and 31 May 2006, 31,896 patients were enrolled into the study. Mean age of patients was 51.6 years (S.D. 23.0) with 60.0% male. Race distribution was 62.5% Chinese, 19.4% Malay, 12.9% Indian and 5.2% others. Trauma consisted 31.2% of calls and medical 68.8%. 9.7% of cases were priority 1 (most severe) and 70.1% priority 2 (moderate severity). Mean call receipt to arrival at scene was 8.0 min (S.D. 4.8). Call volumes in the day were almost twice those at night, with the most calls on Mondays. We found a definite geographical distribution pattern with heavier call volumes in the suburban town centres in the Eastern and Southern part of the country. We characterised the top 35 districts with the highest call volumes by time periods, which will form the basis for ambulance deployment plans.</p><p><b>CONCLUSION</b>We found a definite geographical distribution pattern of ambulance calls. This study demonstrates the utility of GIS with despatch demand analysis and has implications for maximising the effectiveness of ambulance deployment.</p>

Observational study to determine factors associated with blood sample haemolysis in the emergency department

<p><b>INTRODUCTION</b>Haemolysis of blood samples is a common problem encountered in the Emergency department (ED). It leads to inaccurate blood results and has cost implications as blood samples very often have to be retaken. The purpose of our study was to determine which factors in blood sampling were associated with higher rates of haemolysis.</p><p><b>MATERIALS AND METHODS</b>An observational convenience sample of all patients presenting to the ED requiring blood urea and electrolyte (UE) analysis were eligible for our study. Questionnaires were distributed to the doctors and nurses conducting blood sampling to determine the method used and outcome data were collected after the samples were processed.</p><p><b>RESULTS</b>Out of 227 UE samples analysed, 45 (19.8%) were haemolysed. Various factors, including method (IV cannulation or venepuncture), system (syringe or vacutainer), operator, rate of blood flow, difficulty of cannulation/venepuncture and source of blood (arterial or venous), were analysed, but their effects on haemolysis were not statistically significant (P >0.05). However, the use of the vacutainer system was associated with the highest rates of haemolysis [adjusted odds ratio (OR), 6.0; 95% confidence interval (CI), 2.3 to 15.1].</p><p><b>CONCLUSION</b>We found blood sampling with the vacutainer system to have increased rates of haemolysis. This could potentially change attitudes towards equipment used for blood sampling in the ED.</p>