Retrospective review of work-related injuries sustained by foreign workers: a single centre experience over 10 years.

OBJECTIVES: To investigate current patterns of work-related injuries sustained by foreign workers in Singapore and compare them to a decade ago. Secondary aim to analyse usefulness of selected trauma scores in this context. DESIGN: Retrospective review of trauma registry of a single centre, from 1 April to 30 June 2015. Data compared with those from similar study performed at same centre in 2004. SETTING: Emergency department (ED) of 1500-bedded acute urban public hospital in Singapore. PARTICIPANTS: 1094 foreign workers with work-related injuries were included. Tourists, foreign students, non-work-related injuries, re-attendances for the same condition were excluded. RESULTS: Mean age of participants was 32.8 years (SD 7.8), 90.0% were men. ED attendance was lowest on Sundays. Mechanism of injury: blunt (78.2%), penetrating (19.2%), burns (2.6%). Compared to 2004, 5% of foreign workers required admission (vs 19.6% in 2004, p≤0.0001), 8.0% underwent day or inpatient surgical procedures (vs 13.2% in 2004, p≤0.0001), 41.6% were referred to specialist outpatient clinics (vs 27.6% in 2004, p≤0.0001), 12.5% were referred to primary care follow-up (vs 29.9% in 2004, p≤0.0001). Mean duration of sick days was 4.3 (vs 5.1 in 2004, p≤0.0001). Of admitted patients, 49.1% had extremity injuries and 36.3% had head and neck injuries. Mean Injury Severity Score (ISS) for admitted patients was 3.64 (SD 3.1) (vs 4.3 (SD 5.5) in 2004, p=0.39). Mean Revised Trauma Score (RTS) for admitted patients was 7.74 (SD 0.39) (vs 7.8 (SD 0.2) in 2004, p=0.07). Of discharged patients, 48.9% had extremity injuries and 48.9% had external injuries. There was no death. CONCLUSION: Compared to 2004, there were fewer major/fatal work-related injuries and an increased proportion of minor injuries. ISS and RTSs were of limited use in this setting.

The role of training in student examiner rating performance in a student-led mock OSCE.

INTRODUCTION: Peer assessments are increasingly prevalent in medical education, including student-led mock Objective Structured Clinical Examinations (OSCE). While there is some evidence to suggest that examiner training may improve OSCE assessments, few students undergo training before becoming examiners. We sought to evaluate an examiner training programme in the setting of a student-led mock OSCE. METHODS: A year­2 mock OSCE comprised of history taking (Hx) and physical examination (PE) stations was conducted involving 35 year­3 (Y3) student examiners and 21 year­5 (Y5) student examiners who acted as reference examiners. Twelve Y3 student-examiners attended an OSCE examiner training programme conducted by senior faculty. During the OSCE, Y3 and Y5 student examiners were randomly paired to grade the same candidates and scores were compared. Scores for checklist rating (CR) and global rating (GR) domains were assigned for both Hx and PE stations. RESULTS: There was moderate to excellent correlation between Y3 and Y5 student examiners for both Hx (ICC 0.71-0.96) and PE stations (ICC 0.71-0.88) across all domains. For both Hx and PE stations, GR domain had poorer correlation than CR domains. Examiner training resulted in better correlations for PE but not Hx stations. Effect sizes were lower than the minimum detectible effect (MDE) sizes for all comparisons made. DISCUSSION: Y3 student examiners are effective substitutes for Y5 student examiners in a Y2 mock OSCE. Our findings suggest that examiner training may further improve marking behaviour especially for PE stations. Further studies with larger sample sizes are required to further evaluate the effects of dedicated examiner training.

Injury patterns in elderly cyclists and motorcyclists presenting to a tertiary trauma centre in Singapore.

INTRODUCTION: With Singapore's ageing population, there are increasing numbers of elderly cyclists and motorcyclists. Compared to younger riders, this cohort sustains more injuries and has poorer outcomes. This study aimed to describe and compare patient demographics, injury patterns and outcomes among elderly cyclists and motorcyclists at a Level 1 trauma centre. METHODS: Data of all cyclists, motorcyclists and pillion riders aged 65 years and above who presented to the emergency department after accidents from 1 January 2013 to 31 December 2017 was extracted from the hospital's trauma registry and reviewed. RESULTS: Cyclists and motorcyclists formed 42.0% and 58.0%, respectively, of 157 recruited patients. At the time of the accident, 40.8% of the patients were employed. The mean age of the patients was 71.6 ± 5.8 years. Extremities and pelvic girdle injuries (61.1%) were the most frequent, followed by chest injuries (48.4%), and head and neck injuries (40.1%). Among severe injuries (defined as Abbreviated Injury Scale score ≥ 3), chest injuries (39.5%) were the most common, followed by head and neck injuries (36.3%). The overall mortality rate was 9.6%, with cyclists at nearly three times the risk compared to motorcyclists. More cyclists than motorcyclists (18.2% vs. 11.0%) required intensive care. There were no significant differences in the length of hospital stay between cyclists and motorcyclists. CONCLUSION: Elderly riders have unique injury patterns and consume significant healthcare resources. Trauma systems need to acknowledge this changing injury epidemiology and equip trauma centres with the necessary resources targeted at elderly patients. Future work should focus on strategies to minimise extremity and chest injuries.

Tensions in integrating clinician and educator role identities: a qualitative study with occupational therapists and physiotherapists.

OBJECTIVE: Clinician educators (CEs) frequently report tensions in their professional identities as clinicians and educators, although some perceive a reciprocal relationship between clinical and teaching roles. However, it is unknown if the shared meanings of clinicians' multiple job roles translate to identity verification. We sought to examine CEs' perceptions of their clinician and educator roles and the influence of their perceptions on the salience of their professional identities. DESIGN: Qualitative individual interviews and focus groups, analysed using framework analytic approach. SETTING AND PARTICIPANTS: 23 occupational therapy (OT) and 16 physiotherapy (PT) educators from two acute hospitals and one rehabilitation unit in Singapore. RESULTS: PT and OT CEs constructed shared meanings of their clinician and educator roles through overcoming feelings of unease and inadequacy, discovering commonalities and establishing relevance. However, shared meanings between clinician and educator roles might not necessarily lead to mutual verification of their professional identities. Individuals' cognitive flexibility and openness to additional roles, and organisations' expectations had a mediating effect on the identity integration process. Less experienced CEs reported feelings of distress juggling the competing demands of both clinician and educator roles, whereas more experienced CEs appeared to be more capable of prioritising their job roles in different situations, which could be a result of differences in adaptation to frequent interruptions in clinical setting. Emphasis on patient statistics could result in failure in achieving identity verification, leading to feelings of distress. CONCLUSION: Faculty developers should take into consideration the episodic nature of the educator identity construction process and develop induction programmes to assist CEs in building integrated identities.

Why are you here? Needs analysis of an interprofessional health-education graduate degree program.

Little is known about the nature of faculty development that is needed to meet calls for a focus on quality and safety with particular attention to the power of interprofessional collaborative practice. Through grounded-theory methodology, the authors describe the motivation and needs of 20 educator/clinicians in multiple disciplines who chose to enroll in an explicitly interprofessional master's program in health profession education. The results, derived from axial coding described by Strauss and Corbin, revealed that faculty pursue such postprofessional master's degrees out of a desire to be better prepared for their roles as educators. A hybrid-delivery model on campus and online provided access to graduate degrees while protecting the ability of participants to remain in current positions. The added benefit of a community of practice related to evidence-based and innovative models of education was valued by participants. Authentic, project-based learning and assessment supported their advancement in home institutions and systems. The experience was described by participants as a disruptive innovation that helped them attain their goal of leadership in health profession education.

Observer-Reporter-Interpreter-Manager-Educator (ORIME) Framework to Guide Formative Assessment of Medical Students.

The Observer-Reporter-Interpreter-Manager-Educator (ORIME) is adapted from RIME, an intuitive, self-explanatory and "synthetic" framework that assesses formatively, a student's ability to synthesise knowledge, skills and attitude during a clinical encounter with a patient. The "O" refers to a student's ability to pay attention and perceive with open-mindedness, people and events around him or her. The framework is suitable for definition of interim outcomes in a 5-year undergraduate programme. To align students' and clinical teachers' expectations further, selection of case complexity that is commensurate with student's seniority and competence should be guided and an adapted version of the Minnesota Complexity Assessment Tool is proposed.

New house-officers' views on unprofessional behaviour.

AIM: To determine the views of new house officers (HO) on professionalism and unprofessional behaviour following dismissal in January 2007 of a HO who was caught video-taping nurses in the shower. METHODS: An anonymous self-administered questionnaire was administered during new house officers' orientation. Using a Likert scale (1 = strongly disagree to 5 = strongly agree), HO were asked to rank statements regarding teaching and their understanding of professionalism and professional behaviour, role model-clinicians, their response to 3 real-life examples of unprofessional behaviour, and dismissal and Singapore Medical Council (SMC) registration of the sacked HO. Participation was voluntary. RESULTS: Twenty-eight out of twenty-nine (96.6%) international medical graduates (IMG) and 84/95 (88%) house officers who graduated from National University of Singapore (NUS) responded. Their median age was 24 years and 63 of them were male. All IMG compared to 63.1% NUS HO agreed that professionalism was well taught in their medical school (P <0.0001). Majority (82.1%) of IMG compared to 67.9% NUS HO agreed they had adequate role model-clinicians exemplifying professionalism (P <0.0001). Majority (90.8%) of the respondents agreed that the sacked HO's behaviour was not pardonable, a smaller proportion (83.9%) agreed with dismissal but only half (52.7%) agreed that SMC should not register the sacked HO. CONCLUSION: In this study, only two-thirds of NUS HO felt that professionalism was well taught and they had adequate role models. NUS should review this aspect of medical education. Majority of HO agreed with the dismissal but only half felt the misdemeanor was serious enough for SMC not to register the sacked HO.

360 Degrees feedback for emergency physicians in Singapore.

OBJECTIVES: To determine if emergency physicians (EPs) are ready to accept 360 degrees feedback, and agreement between self and colleagues' assessment in a 360 degrees feedback for EPs. METHODS: Self-administered questionnaire to determine acceptability of 360 degrees feedback (n = 43). Each EP completed the Physician Achievement Review self-assessment and approached five colleagues to complete an assessment for him/her. RESULTS: Thirty-one responded: 77.4% preferred to select their appraisers, 90.3% wanted feedback to be confidential, 58.1% would share feedback with supervisors, but only 35.5% would link feedback to remuneration. Colleagues rated EPs' holistic management, humanistic aspects and patient communication, and professional relationship with colleagues as weak domains, weaknesses which EPs were only partially aware. CONCLUSIONS: EPs would accept 360 degrees feedback provided that they selected their appraisers and results were confidential. Colleagues reported that EPs were weak in "soft" and system skills.

Evolution of an emergency department screening questionnaire for severe acute respiratory syndrome.

OBJECTIVES: To describe the screening tool that was used to screen for severe acute respiratory syndrome (SARS), the three revisions that were made, and the factors that led to these revisions. On March 13, 2003, on receiving notification of an outbreak of atypical pneumonia, nurses from the study emergency department (ED) started screening patients for the disease that became known as SARS. METHODS: The ED nurses started with a simple screening tool that was incorporated into triage. The screening tool was later revised into a questionnaire. An outdoor screening station was set up and patients were subsequently screened before triage. After the patients were screened, they were assigned to different risk areas, where triage and treatment were rendered. Two further revisions were made to the questionnaire. RESULTS: From March 13 to May 31, 11457 patients were screened. Version One of the screening questionnaire was used to screen 72 patients from March 13 to 17, Version Two screened 93 patients from March 18 to 21, Version Three screened 2909 patients from March 22 to April 8, and Version Four screened 8383 patients from April 9 to May 31. There was a significant (p < 0.05) downward trend in the proportion of admissions. Among those discharged from the ED, 0.28% reattended and were later confirmed to have SARS. CONCLUSIONS: The screening tool underwent three major revisions in response to new information. By keeping it relatively simple, user-friendly, and regularly updated, nurses were able to screen patients rapidly. Risk categorization ensured that no cross-infection occurred among patients and that no one contracted SARS in the ED.

An emergency department response to severe acute respiratory syndrome: a prototype response to bioterrorism.

STUDY OBJECTIVE: On March 13, 2003, Singapore physicians were alerted about an outbreak of atypical pneumonia that became known as severe acute respiratory syndrome (SARS). I describe the application of an emergency department (ED) disaster response plan to manage the SARS outbreak. METHODS: The ED implemented protection for staff, patients, and facility; infection control measures; and disaster-response workflow changes. The Ministry of Health, Singapore, centralized SARS cases in the hospital, and the ED became the national screening center. A screening questionnaire and a set of admission criteria were applied after assessment of clinical features and chest radiograph findings. RESULTS: For the duration of the outbreak that ended on May 31, 2003, the ED screened 11,461 persons for SARS, of whom 1,386 (12.9%) were admitted to rule out SARS and 235 (17%) were confirmed to have SARS. Among 10,075 persons discharged from the ED, there were 28 reattending patients who were admitted and diagnosed with SARS, giving an undertriage rate of 0.3% (95% confidence interval [CI] 0.1% to 0.4%). The sensitivity of an ED admission for SARS was 89.4% (95% CI 85.6% to 93.1%), and specificity was 89.7% (95% CI 89.2% to 90.3%). The positive predictive value was 17% (95% CI 15.7% to 18.4%), and the negative predictive value was 99.7% (95% CI 99.6% to 99.8%). No patient contracted SARS as a result of an ED visit. After full implementation of protective measures, 1 ED nurse with undiagnosed diabetes mellitus was treated for suspected SARS. CONCLUSION: Although the SARS outbreak was not a bioterrorism event, the ED disaster response was applicable in the outbreak's management. The use of a screening questionnaire and admission criteria enabled the ED to screen, treat, and safely discharge the majority of the patients.