Are We in Control of Our Demons?: Understanding Compassion Satisfaction, Compassion Fatigue and Burnout in an Asian Pediatric Emergency Department in a Pandemic.

BACKGROUND: The medical profession, with its remarkable physical and emotional demands, predisposes physicians to compassion fatigue (CF) and burnout (BO). Although these conditions have been studied individually, little attention has been paid to how pediatric emergency physicians experience these conditions in the context of an Asian emergency setting especially during a global pandemic In our study, we aim to understand the experiences of individual physicians and describe the potential triggers or protective factors of compassion satisfaction, BO, and compassion satisfaction among physicians in an Asian pediatric emergency department during a pandemic. METHODS: A qualitative, individual interview methodology was used. From March to April 2020, we enrolled 20 physicians involved in frontline care during the coronavirus disease 2019 (COVID-19) pandemic in the pediatric emergency department to participate. Semistructured interviews were conducted, audiotaped, and transcribed in verbatim, with identifiers removed. Themes were identified, and data were analyzed using qualitative data analysis and iterative data analysis. RESULTS: We recruited 20 physicians. Three themes emerged from data analysis. First, we showed how workplace conditions are protective, including work morale, leadership and management, and social support received. Second, workload affected participants emotionally and in terms of its heavier quantity and longer hours. Finally, intrinsic factors that were protective in developing CF or BO include having professional autonomy, experience, work-life balance, and having emotional resilience to develop self-care. Cultural influences affect emotional regulation and can lead to negative coping with negative peer pressure. In general, participants quantified their levels of satisfaction at work as average to above average. However, they highlighted experiencing greater stress during COVID-19 with the underlying fear of contagion and infection. CONCLUSIONS: Being a pediatric emergency physician puts one at greater risk of experiencing CF and BO because of work and nonwork stressors, especially during a global pandemic, influenced by sociocultural factors. A positive and supportive work environment should be created while providing culturally adapted strategies to improve individual physician resilience to maintain their well-being.

Appropriateness of paediatric emergency department attendances: patterns, predictors, and how it changed during the COVID-19 pandemic

BackgroundNon-urgent emergency department attendances are a pervasive global problem, contributing to delayed treatment, patient dissatisfaction, and increased admissions. In paediatric emergency departments (PEDs), 41–79% of attendances are non-urgent. Nevertheless, parents and primary care practitioners continue to view PEDs as an appropriate place to seek treatment for minor ailments, with a common reason being its convenience in performing laboratory and radiological investigations in the same location. Resource utilisation is a commonly used measure of appropriateness of an attendance, and is a suitable measure in the unique paediatric population.ObjectivesOur study aims to assess the appropriateness of PED attendances in a multi-ethnic Asian population, and identify predictors of inappropriate attendances (IAs). To our knowledge, no similar study has been performed in a multi-ethnic Asian population. This will allow identification of gaps in our healthcare system that can be addressed to decrease the proportion of inappropriate PED attendances. In the COVID-19 era, we also aim to review how these trends have changed in a pandemic.MethodsA retrospective study was performed on all attendances to the largest PED in Singapore from 1 January to 31 July 2019 and 2020. A total of 153,631 visits were included for analysis.Attendances were classified into appropriate or inappropriate depending on resources used and eventual disposition. An appropriate attendance (AA) was defined as fulfilling any of the following criteria: (1) investigated in emergency department (excluding urine studies in children aged 3 years and older);(2) treated in emergency department (excluding basic enteral anti-pyretic medications, prescription medications, or performing of simple procedures);or (3) admitted to the inpatient ward or discharged with specialist follow-up. All other attendances were hence classified as inappropriate attendances (IAs).Univariate and multivariate analysis was performed to identify predictors of inappropriate attendances.ResultsA total of 31,657 attendances (20.6%) were classified as inappropriate attendances. On multivariate analysis, the three most significant factors predicting inappropriate attendances were lower triage acuity (P3 vs P1, OR 37.37, 95%CI 27.73–50.36), mode of arrival (self vs ambulance or police escort, OR 1.76, 95%CI 1.60–1.94), and first visits (re-attendance within 72 hours vs first visit, OR 0.56, 95%CI 0.50–0.64). Attendances in 2020 decreased by 40.2% from 2019, with a smaller proportion of inappropriate attendances in 2020 (21.7% in 2019 vs 18.8% in 2020, p < 0.001). Similarly, abscondment rates (0.41% in 2019 vs 0.31% in 2020) and re-attendance rates (1.4% in 2019 and 1.2% in 2020) decreased in 2020.ConclusionsThis study identified the frequency of inappropriate visits, and predictors of these visits. From our data, possible initiatives to decrease inappropriate PED use would be to equip PCPs with facilities for basic fingerpick blood tests for the paediatric population. This study paves the way for direction of future research and educational efforts towards these groups to decrease inappropriate use of the emergency department.

Are we in control of our demons? Understanding compassion satisfaction, compassion fatigue and burnout in an Asian paediatric emergency in a pandemic

BackgroundThe medical profession, with its remarkable physical and emotional demands, predisposes physicians to compassion fatigue (CF) and burnout (BO). Though these conditions have been studied individually, little attention has been paid to how pediatric emergency physicians experience these conditions in the context of an Asian emergency setting especially during a global pandemic.ObjectivesIn our study, we aim to understand the experiences of individual physicians and describe the potential triggers or protective factors of CS, BO and compassion satisfaction (CS) amongst physicians in an Asian pediatric emergency department during a pandemic.MethodsA qualitative, individual interview methodology was employed. From March to April 2020, we enrolled 20 physicians involved in frontline care during the coronavirus disease 2019 (COVID-19) pandemic in the pediatric emergency department to participate. Semi-structured interviews were conducted, audiotaped and transcribed in verbatim, with identifiers removed. Themes were identified and data analysed using qualitative data analysis and iterative data analysis.ResultsWe recruited 20 physicians. Three themes emerged from data analysis. Firstly, we showed how workplace conditions are protective, including work morale, leadership and management and social support received. Secondly, workload affected participants emotionally and in terms of its heavier quantity and longer hours. Finally, intrinsic factors that were protective in developing CF or BO include having professional autonomy, experience, work-life balance and having emotional resilience to develop self-care. Cultural influences affect emotional regulation and can lead to negative coping with negative peer pressure. In general, participants quantified their levels of satisfaction at work as average to above-average. However, they highlighted experiencing greater stress during COVID-19 with the underlying fear of contagion and infection.ConclusionsBeing a pediatric emergency physician puts one at greater risk of experiencing CF and BO because of work and non-work stressors especially during a global pandemic, influenced by sociocultural factors. A positive and supportive work environment should be created while providing culturally-adapted strategies to improve individual physician resilience to maintain their well-being

Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has impacted the provision of health services in all specialties. We aim to study the impact of COVID-19 on the utilization of pediatric hospital services including emergency department (ED) attendances, hospitalizations, diagnostic categories and resource utilization in Singapore. METHODS: We performed a retrospective review of ED attendances and hospital admissions among children < 18 years old from January 1st to August 8th 2020 in a major pediatric hospital in Singapore. Data were analyzed in the following time periods: Pre-lockdown (divided by the change in Disease Outbreak Response System Condition (DORSCON) level), during-lockdown and post-lockdown. We presented the data using proportions and percentage change in mean counts per day with the corresponding 95% confidence intervals (CIs). RESULTS: We attended to 58,367 children with a mean age of 5.1 years (standard deviation, SD 4.6). The mean ED attendance decreased by 331 children/day during lockdown compared to baseline (p < 0.001), attributed largely to a drop in respiratory (% change - 87.9, 95% CI - 89.3 to - 86.3, p < 0.001) and gastrointestinal infections (% change - 72.4, 95%CI - 75.9 to - 68.4, p < 0.001). Trauma-related diagnoses decreased at a slower rate across the same periods (% change - 40.0, 95%CI - 44.3 to - 35.3, p < 0.001). We saw 226 children with child abuse, with a greater proportion of total attendance seen post-lockdown (79, 0.6%) compared to baseline (36, 0.2%) (p < 0.001). In terms of ED resource utilization, there was a decrease in the overall mean number of procedures performed per day during the lockdown compared to baseline, driven largely by a reduction in blood investigations (% change - 73.9, 95%CI - 75.9 to - 71.7, p < 0.001). CONCLUSIONS: We highlighted a significant decrease in infection-related presentations likely attributed to the lockdown and showed that the relative proportion of trauma-related attendances increased. By describing the impact of COVID-19 on health services, we report important trends that may provide guidance when planning resources for future pandemics.

Household Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 from Adults to Children.

Knowledge of transmission dynamics of severe acute respiratory syndrome coronavirus 2 from adults to children in household settings is limited. We found an attack rate among 213 children in 137 households to be 6.1% in households with confirmed adult 2019 novel coronavirus disease index case(s). Transmission from adult to child occurred in only 5.2% of households. Young children <5 years old were at lowest risk of infection (1.3%). Children were most likely to be infected if the household index case was the mother.

Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department.

Singapore was one of the earliest countries affected by the coronavirus disease 2019 (COVID-19) pandemic, with more laboratory-confirmed COVID-19 cases in early February 2020 than any other country outside China. This short report is a narrative review of our tertiary paediatric emergency department (ED) perspective and experience managing the evolving outbreak situation. Logistic considerations included the segregation of the ED into physically separate high-risk, intermediate-risk and low-risk areas, with risk-adapted use of personal protective equipment (PPE) for healthcare personnel in each ED area. Workflow considerations included the progressive introduction of outpatient COVID-19 testing in the ED for enhanced surveillance; adapting the admissions process particularly for high-risk and intermediate-risk cases; and the management of unwell accompanying adult caregivers. Manpower considerations included the reorganisation of medical manpower into modular teams to mitigate the risk of hospital transmission of COVID-19. Future plans for a tiered isolation facility should include structural modifications for the permanent isolation facility such as anterooms for PPE donning/doffing; replication of key ED functions in the tent facility such as a separate resuscitation room and portable X-ray room; and refresher PPE training. Dynamic reassessment of ED workflow processes, in conjunction with the hospital and national public health response, may help in managing this novel disease entity.