Utilisation of emergency medical service among Singapore patients presenting with ST-segment elevation myocardial infarction: prevalence and impact on ischaemic time.

BACKGROUND: Previous studies in Western countries found that the emergency medical service (EMS) was under-used in patients with myocardial infarction. AIM: We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST-segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom-to-balloon and door-to-balloon times. METHODS: We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively. RESULTS: Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non-EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non-EMS group was more likely to undergo non-urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom-to-balloon time (average difference 81.6 min, P= 0.002). The door-to-balloon time was similar for both groups. CONCLUSION: Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom-to-balloon time.

A review of elderly injuries seen in a Singapore emergency department.

INTRODUCTION: The elderly population in Singapore is steadily increasing, thus increasing the stress on healthcare provision and financing. Elderly injuries result in significant mortality and morbidity. This study aimed to identify the injury patterns, specific risk factors involved and needs of the elderly so that the current emergency model of care for the injured elderly can be improved and injury prevention strategies devised. METHODS: We conducted a retrospective study of all elderly aged 65 years and older seen for trauma in an emergency department over six months. Data captured in the real-time computer system was studied with regard to patient profile, mechanism of injury and patient disposition. RESULTS: 720 patients aged 65 years and older were seen for trauma in the first six months of 2005, accounting for 10.4 percent of the total attendance for that age group. Home injuries (67.9 percent) were the most common, followed by road-related injuries (21.2 percent). 85.3 percent of the injuries were due to falls. 49.9 percent of the patients were admitted to hospital. We also examined the underlying causes of the injuries and the common injuries sustained. CONCLUSION: Injuries in the elderly is a significant problem. Most of the injuries occur at home and falling is the commonest cause. Many of the injuries are potentially preventable. Several possible injury prevention strategies and improvements to the current emergency model of care of the injured elderly are discussed. The establishment of a national elderly injury surveillance database is advocated.

Patients' complaints in a hospital emergency department in Singapore.

INTRODUCTION: This study analysed the complaint rates, profile and trend, and complainant profile of patients' complaints received by the National University Hospital Emergency Medicine Department. An earlier ten-year study (1986-1995) was done on the complaint profile. METHODS: Records of all patients' complaints, solicited and unsolicited, from January 2002 to December 2003, were retrieved from the Medical Affairs and Quality Improvement Unit files. Complaint profile analysed was reason, validity, and outcome of complaint and staff category involved. Complainant profile analysed was relationship of complainant to patient, ethnic group, gender and residence type of the complainant; and age group and triage category of the patient. RESULTS: Complaint case rate was 1.17 per 1,000 visits, with 1.27 complaints per complaint case. The complaints were organisation/logistics (49.0 percent), communication (26.0 percent), standard of care (22.9 percent) and other issues (1.3 percent). Most standard of care (76.0 percent) and half of organisation/logistics complaints (46.8 percent) were not valid. Most communication complaints were valid (73.7 percent) and involved all staff categories equally. Most complaints (82.8 percent) were resolved with an explanation/apology. Age group specific and triage-specific complaint rates were highest among adult patients and among priority 3 patients, respectively; ethnic group and gender-specific complaint rates were highest among Chinese patients and among female patients, respectively. CONCLUSION: Staff-patient communication and organisation/logistics must be continually improved to reduce complaints, while upholding a good standard of care. These would translate into cost savings for all parties. There must also be appropriate checks and balances particularly where complaints are not valid, so that doctors can practice cost-effective medicine.

A review of 2,517 childhood injuries seen in a Singapore emergency department in 1999--mechanisms and injury prevention suggestions.

BACKGROUND: Childhood injuries cause significant mortality and morbidity in Singapore. With injury surveillance, patterns of repeated injury can be identified and injury prevention strategies devised. METHODS: We conducted a retrospective study of all children aged 12 and below seen for trauma in an Emergency Department over one year. Data captured in the real-time computer system was studied with regards to patient profile, mechanism of injury and patient disposition. Clinical summaries were extracted with follow-up telephone interviews done. RESULTS: Two thousand five hundred and seventeen children aged 12 and below were seen for accidental trauma in 1999, accounting for 37.1% of the total attendance for that age. Mean age was 7.7 years with males making up 62.7%. Home injuries (56.4%) were the most common, followed by road-related (14.4%), sports (8.2%) and playground injuries (7.4%). 48.5% sustained head and face injuries. Pre-school children (age <5) were more likely to sustain home injuries (p<0.0001), a higher proportion of head injuries (p<0.0001), foreign bodies, burns and poisoning compared to school-going children (age 6-12), who were more likely to sustain injuries in road accidents, sports, at playgrounds or schools, with more limb, trunk and multi-trauma. We highlight drownings, falls from height, rollover falls from beds, slamming door injuries, the low use of child car restraints, bicycle injuries and playground falls as areas of concern. CONCLUSION: Several injury prevention strategies have been suggested and it is hoped these may contribute to addressing preventable childhood injuries in Singapore. We also advocate the establishment of a national childhood injury surveillance database.

Acute coronary syndrome--factors causing delayed presentation at the Emergency Department.

INTRODUCTION: The aim of the study was to identify factors that contributed to delays in presentation of patients with acute coronary syndrome (ACS) at the Emergency Department (ED). MATERIALS AND METHODS: The study population comprised patients presenting with the signs and symptoms of ACS at the ED of 5 government and restructured hospitals in Singapore from 1 April to 31 May 1999. These patients were interviewed with a structured questionnaire which explored patient demographic data, risk factors, prehospital symptomatology, timing of chest pain, patient response to chest pain and mode of transport to the hospital. RESULTS: Three hundred and two patients who made 307 visits were recruited. More than three-quarters of the patients presented with central or left-sided chest pain. Forty-seven per cent had breathlessness and 42% had sweating. The commonest day of presentation was Monday. It took patients a median time of 2.1 hours from their worst chest pain to arrive at the ED. Past history of diabetes mellitus was associated with a longer delay in presentation. Most of the delay was due to patients awaiting symptom resolution. Forty per cent came by emergency ambulances to hospital. CONCLUSION: Our findings identified various patient characteristics that contributed to delay in presentation to hospital which should be addressed in future education campaigns.

A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).

STUDY OBJECTIVE: We evaluate a new technique of treating scalp lacerations, the hair apposition technique (HAT). After standard cleaning procedures, hair on both sides of a laceration is apposed with a single twist. This is then held with tissue adhesives. HAT was compared with standard suturing in a multicenter, randomized, prospective trial. METHODS: All linear lacerations of the scalp less than 10 cm long were included. Severely contaminated wounds, actively bleeding wounds, patients with hair strand length less than 3 cm, and hemodynamically unstable patients were excluded. Patients were randomized to receive either HAT or standard suturing, and the time to complete the wound repair was measured. All wounds were evaluated 7 days later in a nonblinded manner for satisfactory wound healing, scarring, and complications. RESULTS: There were 96 and 93 patients in the study and control groups, respectively. Wound healing trended toward being judged more satisfactory in the HAT group than standard suturing (100% versus 95.7%; P =.057; effect size 4.3%; 95% confidence interval 0.1% to 8.5%). Patients who underwent HAT had less scarring (6.3% versus 20.4%; P =.005), fewer overall complications (7.3% versus 21.5%; P =.005), significantly lower pain scores (median 2 versus 4; P <.001), and shorter procedure times (median 5 versus 15 minutes; P <.001). There was a trend toward less wound breakdown in the HAT group (0% versus 4.3%; P =.057). When patients were asked whether they were willing to have HAT performed in the future, 84% responded yes, 1% responded no, and 15% were unsure. CONCLUSION: HAT is equally acceptable and perhaps superior to standard suturing for closing suitable scalp lacerations. Advantages include fewer complications, a shorter procedure time, less pain, no need for shaving or removal of stitches, similar or superior wound healing, and high patient acceptance. HAT has become our technique of choice for suitable scalp lacerations.[Ong Eng Hock M, Ooi SBS, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).

The emergency medicine department system: a study of the effects of computerization on the quality of medical records.

A template based computerized medical record system known as the Emergency Medicine Department System (EMDS) was installed in the emergency department of the National University Hospital, Singapore, replacing handwritten records. A study was carried out to show how the implementation of the EMDS improved the quality of medical records. A retrospective review of old manual records and the ones generated by the EMDS was done by means of a scoring system. The raw scores represent the amount of information captured. The calculated means of scores were then used to compare the records. It was found that EMDS improves the quantity of data capture over the old records in all sections compared. This was seen regardless of the experience of the user. The use of a non-structured generic template results in less data captured compared with a structured symptom-specific template. The design of questions has a great influence in that a double-choice question captures more data than single-choice questions. Building in 'locking' or enforcement mechanisms in the EMDS also helped achieve almost full capture of critical information, such as examination time.

Neck pain after minor neck trauma--is it always neck sprain?

We report a patient who had headache and neck pain after whiplash injury and subsequently developed cerebellar infarction due to vertebral artery dissection. This patient's pain was out of proportion to his apparent injury and it was a clue to the final diagnosis. Gross motor examination for cord injury may not be adequate for patients with minor neck trauma. Detailed cranial nerve and cerebellar examination should be performed for detection of circulatory insufficiency. Discharge advice for patients should also include that of stroke or transient ischaemic attack.

Value of troponin-T rapid assay, cardiac enzymes, electrocardiogram and history of chest pain in the initial diagnosis of myocardial infarction in the emergency department.

We conducted a prospective study of 152 adult patients presenting to an emergency department with chest pain or symptoms suggestive of acute myocardial infarction (AMI) to evaluate the first electrocardiogram (ECG), creatine kinase (CK)-MB and Troponin-T Rapid Assay (TnT) alone or in combination with chest pain in the initial diagnosis of AMI. A provisional diagnosis was made after the history, physical examination and the first ECG reading. Blood specimens were taken for TnT, CK and CK-MB mass. A final discharge diagnosis of AMI was made according to World Health Organization criteria. Seventy-six (50%) of patients had a final diagnosis of AMI. The sensitivities of the first ECG, first CK-MB mass and first TnT were 76.3% (95% confidence interval (CI), 66.8-85.9), 38.2% (95% CI, 27.2-49.1) and 31.6% (95% CI, 21.2-42.0) respectively. The area under the curve for a combination of ECG, CK-MB mass, TnT and chest pain was the highest at 0.937 when compared with chest pain with varying combinations of tests. A combination of the first ECG, CK-MB mass and TnT had a negative predictive value (NPV) of 87.9% (95% CI, 80.0-95.8). The first ECG was the most sensitive test while the combination of chest pain, ECG, cardiac enzymes and TnT gave the best results in the initial diagnosis of AMI. If the first ECG, CK-MB mass and TnT are all negative, the probability of having an AMI is 12%.

Haematuria in the diagnosis of urinary calculi.

The aims of this study were to compare the sensitivity of urine dipstix (Combur 9 test) versus urine microscopy in detecting haematuria and to determine the proportion of patients with renal or ureteric colic due to urinary calculi who have haematuria. This is a prospective study of 122 patients presenting to an emergency department in a tertiary teaching hospital with symptoms suggestive of renal or ureteric colic. The same urine specimen tested using dipstix was sent for urine microscopic examination for haematuria, after which a plain radiograph of the kidneys, ureter and bladder was done. An early intravenous urogram was done (delay of an average of 4 days). Telephone interviews were done to determine whether any calculi had been passed. Urine dipstix detected haematuria in 95.4% [95% confidence intervals (CI) 87.1% to 100.0%] of patients with urinary calculi, whilst urine microscopy detected haematuria in 70.8% (95% CI 58.2% to 92.6%). This study showed that urine Combur 9 is more sensitive than urine microscopy in detecting haematuria. The combined use of urine Combur 9 and microscopy does not increase the sensitivity of detecting haematuria. In the absence of haematuria on urine Combur 9 for suspected ureteric colic, alternative diagnoses should be considered.

Emergency department complaints: a ten-year review.

This 10-year (May 1986-31 December 1995) retrospective study was done to analyse the types of complaints received by the National University Hospital's Emergency Department (NUH EMD), so as to take remedial measures. It was done by reviewing three sources of complaints received by the department, namely formal written complaints, verbal feedback received by the Corporate Affairs Department, and via feedback forms. The areas of complaints looked for included the nature, number, validity, whether remediable and triage priority of the patients. One hundred and eighty-eight subcategories of complaints were received from 169 complaints. The complaint frequency was 0.26 per 1,000 visits or 1 complaint per 3,846 visits. The complaint frequency over the 10 years did not vary much (range 0 to 0.44). Most of the complaints are divided into 4 broad categories ie medical, doctor-patient/paramedical staff-patient relationship, patient flow/logistics at EMD and in-house complaints. The majority (71.3%) of the complaints were due to medical and doctor-patient relationship problems. Complaints tend to arise from Priority 2 and 3 rather than Priority 1 patients. 33.7% of the complaints were considered valid, 21.6% not valid while in the remaining 44.7%, validity could not be determined. 48.4% of complaints were likely to be remediable. Based on this study, we have since instituted a compulsory emergency department-driven "Customer Service Training Programme" and weekly teaching sessions for each incoming group of medical officers posted to the NUH EMD.