Evaluating the association of COVID-19 restrictions on discharge planning and post-discharge outcomes in the community hospital and Singapore regional health system.

Objectives: The COVID-19 is a global health issue with widespread impact around the world, and many countries initiated lockdowns as part of their preventive measures. We aim to quantify the duration of delay in discharge to community from Community Hospitals, as well as quantify adverse patient outcomes post discharge pre and during lockdown period. Design and methods: We conducted a before-after study comparing the length of stay in Community Hospitals, unscheduled readmissions or Emergency Department attendance, patients' quality of life using EQ5D-5l, number and severity of falls, in patients admitted and discharged before and during lockdown period. Results: The average length of stay in the lockdown group (27.77 days) were significantly longer than that of the pre-lockdown group (23.76 days), p = 0.003. There were similar proportions of patients with self-reported falls post discharge between both groups. Patients in the pre-lockdown group had slightly better EQ-5D-5l Index score at 0.55, compared to the lockdown study group at 0.49. Half of the patients in both groups were referred to Community Care Services on discharge. Conclusion: Our study would help in developing a future systematic preparedness guideline and contingency plans in times of disease outbreak and other similar public health emergencies.

Association of Social Support with Rehabilitation Outcome among Older Adults with Hip Fracture Surgery: A Prospective Cohort Study at Post-Acute Care Facility in Asia.

OBJECTIVES: There is growing interest in the role of social support during the recovery after hip fractures. The research to date has been mainly focused on structural support, with few studies concerned with functional support. This study examined the effects of both functional and structural aspects of social support on rehabilitation outcomes among older adults with hip fracture surgery. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Consecutive older adults (≥60 years) with hip fracture surgery who underwent inpatient rehabilitation in a post-acute care facility in Singapore between January 11, 2021, and October 30, 2021 (n = 112). METHODS: We administered the Medical Outcome Study-Social Support Survey (MOS-SSS) to assess perceived functional support of patients and used living arrangement as an indicator for structural support. Participants were followed up over the inpatient stay at the post-acute care facility until discharge; thereafter, rehabilitation efficiency (REy) and rehabilitation effectiveness (REs) were evaluated. Multiple linear regressions were performed to examine the associations of MOS-SSS score and living arrangement with REy and REs, respectively, adjusting for age, gender, ethnicity, comorbidity, body mass index, prefracture function, type of fracture, and length of stay. RESULTS: Perceived functional support had positive associations with rehabilitation outcomes. A 1-unit increase in MOS-SSS total score was associated with 0.15 units (95% CI 0.03-0.3, P = .029) greater gain in physical function after a typical 1-month stay, and 0.21 units (95% CI 0.01-0.41, P = .040) higher achievement in potential functional improvement upon discharge. In contrast, no association was observed between structural support and rehabilitation outcomes. CONCLUSIONS AND IMPLICATIONS: Perceived functional support may significantly impact the recovery of older adults with hip fracture during the inpatient rehabilitation process, independent of structural support. Our findings suggest the potential of incorporating interventions enhancing perceived functional support of patients into the post-acute care model for hip fracture.

Impact of COVID-19 Measures on Discharge Planning and Continuity of Integrated Care in the Community for Older Patients in Singapore.

Introduction: The COVID-19 pandemic affects the process of care transition for patients with underlying chronic conditions. This study aims to explore the impact of the pandemic measures on discharge planning and continuum of care for vulnerable older patients from multi-stakeholder perspectives. Methods: We conducted focus group discussions and individual interviews with healthcare workers, community partners, government officials and family caregivers in Singapore. All interviews were audio-recorded, transcribed verbatim and thematically analysed. Results: A total of 53 individuals participated in the study. Discharge planning and care continuity in the community were affected primarily by the limited step-down care options and remote assessment of discharge needs. Participants felt a need to revisit the decision of 'essential' community services through engagement of all stakeholders to enhance care community.To improve better care transition, participants suggested the need for clearer communication of guidelines, improved intersectoral collaboration, shared responsibility of patient care through community engagement and employment of novel models of care. Conclusion: The pandemic measures generated challenges of safe discharge of patients and care continuity in the community. Findings shed light on the need to proactively assess care pathways and catalyse novel models to improve care transition beyond the pandemic.

Implementing a community-based shared care breast cancer survivorship model in Singapore: a qualitative study among primary care practitioners.

BACKGROUND: The adaptability of existing recommendations on shared care implementation to Asian settings is unknown. This qualitative study aims to elicit public- and private-sectors primary care practitioners' (PCPs) perspectives on the sustainable implementation of a shared care model among breast cancer survivors in Singapore. METHODS: Purposive sampling was employed to engage 70 PCPs from SingHealth Polyclinics, National University Polyclinics, National Healthcare Group Polyclinics, and private practice. Eleven focus groups and six in-depth interviews were conducted between June to November 2018. All sessions were audio-recorded and transcribed verbatim. Guided by the RE-AIM framework, we performed deductive thematic analysis in QSR NVivo 12. RESULTS: PCPs identified low-risk breast cancer survivors who demonstrated clear acceptability of PCPs' involvement in follow-up as suitable candidates for shared care. Engagement with institution stakeholders as early adopters is crucial with adequate support through PCP training, return pathways to oncologists, and survivorship care plans as communication tools. Implementation considerations differed across practices. Selection of participating PCPs could consider seniority and interest for public and private practice, respectively. Proposed adoption incentives included increased renumeration for private PCPs and work recognition for public PCPs. Public PCPs further proposed integrating shared care elements to their existing family medicine clinics. CONCLUSIONS: PCPs perceived shared care favorably as it echoed principles of primary care to provide holistic and well-coordinated care. Contextual factors should be considered when adapting implementation recommendations to Asian settings like Singapore. With limited competitive pressure, the government is then pivotal in empowering primary care participation in survivorship shared care delivery.

Impact of malnutrition in surgically repaired hip fracture patients admitted for rehabilitation in a community hospital: A cohort prospective study.

BACKGROUND: Malnutrition is common and associated with adverse outcomes in geriatric patients with hip fractures. The study aims to evaluate the relationship between the nutritional status and rehabilitation efficiency and functional outcome on discharge in postoperative hip fracture patients. METHODS: We prospectively evaluated 172 postoperative hip fracture patients who were admitted to the community hospital from November 2019 to November 2020. Nutritional status was assessed by the 7-point Subjective Global Assessment (SGA) within 48 h of admission. Patients were assessed for rehabilitation efficiency and functional outcome at the end of their inpatient stay. RESULTS: There were 172 patients recruited with 100 (58.1%) malnourished and 72 (41.9%) well-nourished patients. Patients in the malnourished group were significantly older, needed walking aid assistance prior to sustaining hip fracture, cognitively impaired and had more comorbidities. Malnourished patients had lower rehabilitation efficiency scores (0.27, 95% CI -0.12 - 0.67 vs 1.32, 95% CI 0.88-1.76) and poorer functional outcomes on discharge (OR 21.5, 95% CI 2.45-188.7, p-value <0.001), after adjustment for pre- and post-fracture confounders. CONCLUSION: Malnutrition was present in more than half the postoperative hip fracture patients admitted to a community hospital in Singapore. This study showed that poor nutritional status is associated with significantly lower rehabilitation efficiency and functional outcome on discharge in hip fracture patients. Given the medical, social and economic stakes relating to hip fractures, it is essential to recognise and treat malnutrition in the hospital and community.

Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BACKGROUND: Breast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so. OBJECTIVE: To explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists. METHODS: Eleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12. RESULTS: Majority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme. CONCLUSIONS: PCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation.

Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review.

BACKGROUND: Hip fracture is an important and prevalent medical condition associated with adverse outcomes. The aim of this article is to systematically review and summarise the predictors of poor functional outcomes and mortality for patients with hip fractures. METHODS: We conducted a systemic literature search using PubMed, EMBASE and Cochrane Library. We included English peer-reviewed cohort studies that examined predictors of poor functional outcomes (such as independence in Activities of Daily Living) and mortality for patients with hip fracture published in the past 15 years (from 1 Jan 2004 up to 30 May 2019). Two independent researchers evaluated the articles for eligibility. Consensus on the eligibility was sought and a third researcher was involved if there was disagreement. A standardised form was used to extract relevant data. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. RESULTS: We retrieved 4339 and included 81 articles. We identified two emerging predictors of poor functional outcomes and mortality for patients with hip fractures: low hand grip strength and frailty in line with an emerging concept of "physical performance". The predictors identified in this systematic review can be grouped into 1) medical factors, such as presence of co-morbidities, high American Society of Anesthesiologists (ASA) grade, sarcopenia, 2) surgical factors including delay in operation (e.g. > 48 h), type of fracture s, 3) socio-economic factors which include age, gender, ethnicity, and 4) system factors including lower case-volume centers. CONCLUSIONS: This systematic review identified multiple significant predictors of poor functional outcomes and mortality, with the hand grip strength and frailty being important emerging predictors in the most recent literature. These predictors would further inform healthcare providers of their patients' health status and allow for early intervention for modifiable predictors.

Reducing Follow-Up Appointments in a Mental Health Institute in Singapore: Family Medicine-Psychiatry Collaboration.

BACKGROUND: The Institute of Mental Health (IMH), the leading tertiary psychiatric hospital in Singapore, has managed patients' psychiatric issues for decades. However, these patients' existing medical conditions often require care in subspeciality outpatient clinics of restructured hospitals. Given the need to reduce follow-up appointments in subspeciality outpatient clinics for conditions that can be managed by family physicians, a novel family medicine-psychiatry collaborative initiative between Sengkang General Hospital and IMH was implemented to address this issue. METHODS: Data were retrospectively collected on patients with upcoming appointments who were seen by family physicians at IMH from January 2 to May 14, 2017. Patients with upcoming appointments in the subspeciality outpatient clinics were scheduled for review by family physicians. Continuous data were summarized as median (range) and count (percentage). RESULTS: At 4.5 months, 272 patients with 426 preexisting specialty appointments had been seen by family physicians. Of the specialty appointments, 150 (35.2%) were cancelled, as the conditions could be managed by family physicians. In 64 (15.0%) cases, a memo requesting transfer of care was given to the subspecialty consultant to ensure a consensus regarding the patient's management. CONCLUSIONS: Family physicians embedded in mental health institutions can reduce the need to transfer patients out of the hospital to receive care for nonpsychiatric conditions.

A case report of an atypical presentation of pyogenic iliopsoas abscess.

BACKGROUND: Iliopsoas abscess is a collection of pus in the iliopsoas muscle compartment. It can be primary or secondary in origin. Primary iliopsoas abscess occurs as a result of hematogenous or lymphatic seeding from a distant site. This is commonly associated with a chronic immunocompromised state and tends to occur in children and young adults. Secondary iliopsoas abscess occurs as a result of the direct spread of infection to the psoas muscle from an adjacent structure, and this may be associated with trauma and instrumentation in the inguinal region, lumbar spine, or hip region. The incidence of iliopsoas abscess is rare and often the diagnosis is delayed because of non-specific presenting symptoms. CASE PRESENTATION: We describe a patient with iliopsoas abscess who presented to the Emergency Department at X Hospital on three separate occasions with non-specific symptoms of thigh pain and fever before finally being admitted for treatment. This case illustrates how the diagnosis can be delayed due to its atypical presentation. Hence, highlighting the need for clinicians to have a high index of clinical suspicion for iliopsoas abscess in patients presenting with thigh pain and fever. CONCLUSION: The classic triad of fever, flank pain, and hip movement limitation is presented in only 30% of patients with iliopsoas abscess. Clinicians should consider iliopsoas abscess as a differential diagnosis in patients presenting with fever and thigh pain. The rare condition with the varied clinical presentation means that cross-sectional imaging should be considered early to reduce the risk of fulminant sepsis.

Varicella infections in patients with end stage renal disease: a systematic review.

BACKGROUND: End stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination. METHODS: Three databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords 'varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications'. RESULTS: 29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64-94%. CONCLUSION: Varicella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients.

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review.

BACKGROUND: End stage renal disease (ESRD)/ end stage renal failure (ESRF) is on the rise globally and especially in Singapore. Varicella or chickenpox is not uncommon among adults especially ESRD/ESRF patients. It has been reported to cause complications and even death among immunocompetent adults. METHODS: A retrospective data collection on patients with varicella infection and ESRD in Singapore General Hospital (SGH) from the year 2005 to 2016 was performed. Continuous data and categorical data were summarized as median (range) and count (%) respectively. The association of health care utilization (total length of hospital stay, readmission related to varicella, intensive care unit admission) and mortality with complication due to varicella were tested using chi-square and Mann-Whitney test for categorical and continuous outcomes respectively. RESULTS: Sixty-six patients with ESRD developed varicella during the study period (2005-2016). The case incidence rates for varicella among ESRD ranges from 97 to 267 per 100,000 populations with ESRD yearly. There were 9 deaths (13.6%). Mortality was higher among the ESRD patients with one or more varicella complications compared to patients without complications ((25% vs 7.1%, 95% CI for difference: - 1.1%, 36.9%, p = .063). Likewise, utilisation of intensive or high dependency units were higher among patients with complications compared to those without (20.8% vs 2.4%, 95% CI for difference: 1.6%, 35.3%, p = .012). Length of stay was twice as long in the group with complications compared to patients without (median (IQR) days: 14 (8, 21) vs 7 (5, 14), p = .065), although it did not reach statistical significance. CONCLUSIONS: Varicella is associated with high morbidity and significant mortality rate in ESRD patients. Varicella vaccination is recommended for seronegative ESRD patients.

Using the SBAR4 model for Management of a Patient with Complex Comorbidites in the Community Hospital - A Case Study

Patients who require a stay in a community hospital usually tend to be more complex, presenting not only with biomedical issues with complications, but also with a myriad of psychological and social issues as well. If they were to be discharged from an acute hospital directly to primary care and community, the patients and caregivers may feel helpless, overwhelmed and unsure of how to navigate the healthcare system to get their complex issues sorted out. Family physicians in the community hospitals need to hone their skills in such an area of care. The SBAR4 model can be effectively used to categorise the patients’ multiple bio-psycho-social issues, coordinate the multi-disciplinary team to bring hospital and community resources to help such patients, provide holistic care for such patients, and transit them safely into the care of our family physicians in primary care and community.

A case series of atypical presentation of Zika Virus infection in Singapore.

BACKGROUND: The World Health Organization's and Centers for Disease Control and Prevention's definition of Zika infection are symptoms of fever, rash, joint pain, myalgia, headache and conjunctivitis. The diagnosis of Zika infection is based on the clinical history, physical examination and laboratory investigations which includes blood and urine Zika virus Polymerase Chain Reaction. CASE PRESENTATION: Two patients presented with atypical presentation of Zika infection to Sengkang Health, Alexandra Hospital during the recent Zika outbreak in Singapore in August 2016. Madam A presented with isolated generalized rash with no fever, joint pain, myalgia, headache or conjunctivitis. Mr. B presented with isolated fever of 39.4 °C with no rash, joint pain, myalgia, headache or conjunctivitis. Both patients' blood Zika Polymerase Chain Reactions were positive at the time of presentation. CONCLUSION: The described case reports illustrated the challenges that our community Family Physicians faced in diagnosing patients infected with Zika virus. Coupled with the knowledge that most patients are asymptomatic, Family Physicians need to have a high index of clinical suspicion for early identification of patients infected with Zika virus, so as to institute timely treatment and appropriate measures to mitigate the outbreak of Zika infection in the community. Appropriate epidemiological measures such as ensuring prompt and thorough contact tracing of the cases are instrumental in the control of this public health problem.

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996-2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary.