Quality-of-life is reduced in older patients surviving major blunt trauma. Pre-injury frailty, chronic illness, low falls, or head injury, increase the risk of unplanned healthcare utilization and post-discharge mortality. However, post-hospitalization needs and experiences of patients and caregivers from this high-risk group are not well-understood. This mixed-methods longitudinal study aims to understand participants’ perspectives on needs, prognosis, quality-of-life and end-of-life planning, during the post-injury trajectory. High-risk patients > 55-years-old, and their caregivers, were recruited from three hospitals after surviving blunt trauma. All participants allowed the study team access to medical records, including unplanned readmission and death, for 36 months. Participants who consented to longitudinal follow-up were assessed for quality-of-life and caregiver burden at regular intervals. If unplanned readmission or death occurred, the longitudinal group participants were contacted for a semi-structured interview. Out of 155 participants recruited, 71 patients experienced > = 1 unplanned readmission and 33 died. Twelve semi-structured interviews were conducted after unplanned readmission or death. Five unmet needs were extrapolated from qualitative interviews: uncertainty of prognosis; access to financial support; unaddressed social needs; inconsistent access to healthcare and inadequate structural support. Qualitative findings corroborated with and provided context for the quantitative analysis. Patients with high (> = 2) unplanned readmissions, higher co-morbidities or poorer function had lower quality-of-life. For caregiver burden, high-readmission caregivers experienced increasing financial stress over time, but other domain trajectories were similar between high- and low-readmission groups. The study was limited by recruitment and access difficulties caused by the COVID-19 pandemic, and over-representation of the ethnic majority. Older high-risk blunt trauma survivors and caregivers need better support to mitigate uncertainties in their disease trajectory. Future directions include a system-level prompt to identify at-risk patients at discharge, offering access to designated care teams at different time-points to support the patients and caregivers to navigate the many uncertainties in their healthcare journeys.

BACKGROUND:The smartphone application to activate a community first responder (myResponder) was launched in 2015 to activate volunteer first responders for Out-of-Hospital Cardiac Arrest (OHCA) patients in Singapore. This study aimed to investigate the impact of myResponder on provision of bystander CPR, bystander AED, and patient survival outcomes. METHODS:This was a retrospective analysis using the Singapore Pan-Asian Resuscitation Outcomes Study between 2016 and 2019 that included adult non-traumatic OHCA patients. Patients were categorized into myResponder activated and non-activated groups. The primary outcomes were bystander CPR and bystander AED. The secondary outcome was survival at 30-days with favourable neurological outcomes (cerebral performance category 1-2). A multivariable logistic regression analysis was performed and we reported adjusted odds ratio [aOR] and 95% confidence interval for the effect of activation. RESULTS:9,167 patients were included in this analysis. The median (Interquartile range, IQR) age was 71 (59-82) years. The activated group comprised 5,499 (60%) of cases. The activated group was associated with higher bystander CPR (aOR [95%CI]: 5.69 [4.89-6.62]) and bystander AED (aOR [95% CI]: 2.23 [1.82-2.74]) compared to non-activated group. The activated group was associated with better survival at 30 days with favourable neurological outcomes (aOR [95% CI]: 1.54 [1.11-2.15]). CONCLUSION:We found that the implementation of technology-activated first responders was associated with an improvement in the performance of bystander CPR, bystander AED application, and OHCA outcomes in an urban area. Further efforts should be made to promote the use of activated first responders in EMS systems.

Machine learning (ML) methods are increasingly used to assess variable importance, but such black box models lack stability when limited in sample sizes, and do not formally indicate non-important factors. The Shapley variable importance cloud (ShapleyVIC) addresses these limitations by assessing variable importance from an ensemble of regression models, which enhances robustness while maintaining interpretability, and estimates uncertainty of overall importance to formally test its significance. In a clinical study, ShapleyVIC reasonably identified important variables when the random forest and XGBoost failed to, and generally reproduced the findings from smaller subsamples (n = 2500 and 500) when statistical power of the logistic regression became attenuated. Moreover, ShapleyVIC reasonably estimated non-significant importance of race to justify its exclusion from the final prediction model, as opposed to the race-dependent model from the conventional stepwise model building. Hence, ShapleyVIC is robust and interpretable for variable importance assessment, with potential contribution to fairer clinical risk prediction.

BACKGROUND:Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management. METHODS:Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated. RESULTS:A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR. CONCLUSION:The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

Objectives:With more elderly presenting with Out-of-Hospital Cardiac Arrests (OHCAs) globally, neurologically intact survival (NIS) should be the aim of resuscitation. We aimed to study the trend of OHCA amongst elderly in a large Asian registry to identify if age is independently associated with NIS and factors associated with NIS. Methods:All adult OHCAs aged ≥18 years attended by emergency medical services (EMS) from April 2010 to December 2019 in Singapore was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Cases pronounced dead at scene, non-EMS transported, traumatic OHCAs and OHCAs in ambulances were excluded. Patient characteristics and outcomes were compared across four age categories (18-64, 65-79, 80-89, ≥90). Multivariable logistic regression analysis determined the factors associated with NIS. Results:19,519 eligible cases were analyzed. OHCA incidence increased with age almost doubling in octogenarians (from 312/100,000 in 2011 to 652/100,000 in 2019) and tripling in those ≥90 years (from 458/100,000 in 2011 to 1271/100,000 in 2019). The proportion of patients with NIS improved over time for the 18-64, 65-79- and 80-89-years age groups, with the greatest improvement in the youngest group. NIS decreased with each increasing year of age and minute of response time. NIS increased in the arrests of presumed cardiac etiology, witnessed and bystander CPR. Conclusions:Survival with good outcomes has increased even amongst the elderly. Regardless of age, NIS is possible with good-quality CPR, highlighting its importance. End-of-life planning is a complex yet necessary decision that requires qualitative exploration with elderly, their families and care providers.

OBJECTIVES:The relationship between the bystander witness type and receipt of bystander CPR (BCPR) is not well understood. Herein we compared BCPR administration between family and non-family witnessed out-of-hospital cardiac arrest (OHCA). BACKGROUND:In many communities, interventions in the past decade have contributed to an increased receipt of BCPR, for example in Singapore from 15% to 60%. However, BCPR rates have plateaued despite sustained and ongoing community-based interventions, which may be related to gaps in education or training for various witness types. The purpose of this study was to investigate the association between witness type and BCPR administration. METHODS:Singapore data from 2010-2020 was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) network registry (n = 25,024). All adult, layperson witnessed, non-traumatic OHCAs were included in this study. RESULTS:Of 10,016 eligible OHCA cases, 6,895 were family witnessed and 3,121 were non-family witnessed. After adjustment for potential confounders, BCPR administration was less likely for non-family witnessed OHCA (OR 0.83, 95% CI 0.75, 0.93). After location stratification, non-family witnessed OHCAs were less likely to receive BCPR in residential settings (OR 0.75, 95% CI 0.66, 0.85). In non-residential settings, there was no statistically significant association between witness type and BCPR administration (OR 1.11, 95% CI 0.88, 1.39). Details regarding witness type and bystander CPR were limited. CONCLUSION:This study found differences in BCPR administration between family and non-family witnessed OHCA cases. Elucidation of witness characteristics may be useful to determine populations that would benefit most from CPR education and training.

Background The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians’ attitudes and behaviours in four EDs in Singapore. Methods We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. Results We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. Conclusions Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.

OBJECTIVE:We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation. METHODS:All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval. RESULTS:12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97-0.98); survival to discharge- aOR 0.98 (95%CI: 0.98-0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests. CONCLUSION:We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional 'down-times', which could aid clinical decisions in TOR or OHCA management.

INTRODUCTION Overcrowding at Accident and Emergency (A&E) is a global public health issue.[1-3] A&E overcrowding has been associated with negative patient outcomes like increased mortality,[4] reduced quality of care[5] and increased medication errors.[6] Studies have highlighted the use of A&E by non-urgent patients as one of the contributing factors to A&E overcrowding.[7-9] Singapore's A&E visits have grown about 4% annually between 2006 and 2015.[10] This increase is higher than the population growth rate, which is about 1%–2% annually.[11] In 2013, non-urgent visits contributed to >50% of A&E cases at four public hospitals.[12] Hence, there is an urgency to address the issue of non-urgent visits at Singapore's A&E. Non-urgent patients are individuals whose conditions have low urgency and can be handled by other healthcare services such as general practitioners (GPs).[13] Previously, Singapore had implemented interventions to reduce non-urgent A&E visits with varying success.[14] Past education campaigns resulted in reductions, which were not sustained in the longer term. The redirection of patients to other healthcare services often resulted in disputes between A&E staff and patients. Increasing the A&E fees only translated into <10% drop in non-urgent A&E visits.[14] The limited success could be due to the lack of understanding of the health-seeking behaviour of patients with non-urgent conditions. International studies reported that non-urgent patients' choice of healthcare providers was influenced by a few factors, including (a) perception of one's condition's criticality and the need to be reassured,[15-18] (b) preference and greater trust in A&E over other healthcare services,[15,19,20] (c) easier access to A&E relative to other services like GPs[21-23] and (d) financial considerations such as cost and insurance coverage.[15,24] Locally, studies targeting throughput factors such as queuing, scheduling, resource allocation or patient profiling for non-urgent A&E visits are far more pronounced,[25-27] and little work has been done to investigate the issue from a social–psychological angle. To address this gap, we aimed to explore the underlying factors influencing the health-seeking behaviour of patients for non-urgent conditions. METHODS Five focus group discussions (FGDs) were conducted in English by four facilitators in Changi General Hospital (CGH) between March and April 2016. The facilitators had no previous relationship with the participants. FGD was chosen, as the interactive discussions enable the generation of unique data that is not accessible through individual interviews.[28,29] We purposively sampled across two groups: (i) the A&E group and (ii) the GP group. The A&E group comprised patients who were self-referred or referred by their GP to A&E and not admitted. Individuals were approached at A&E while waiting for medication and payment after consultation with the doctor. Not admitting the patients after an emergency consultation suggests that they have non-urgent conditions that can be managed by a GP. Individuals referred to A&E by the GP were included in the sampling strategy to enable us to understand the reasons for the initial choice of GP over A&E. The GP group comprised specialist outpatient clinics (SOCs) patients who did not visit A&E but saw a GP within the last 3 months. We used a semi-structured, pretested topic guide for consistency. An exploratory approach involving experts' inputs (e.g. A&E clinicians) was used to develop the guide, focusing on adaptive questions about the decision-making processes that prompted participants' choice of healthcare providers. The inclusion criteria were individuals aged ≥21 years with no cognitive impairment and English-speaking patients. Each FGD lasted approximately an hour, and discussions were audio-recorded, transcribed verbatim, anonymised and analysed using NVivo for Mac, Version 11.0[30] (Lumivero, Denver, CO, USA) by the first author, based on Braun and Clarke's thematic analysis (TA) approach.[31] Themes were derived from codes and conceptualised based on the patterns identified in the data. The FGDs and analysis occurred iteratively, and data and thematic saturation was reached by the fifth FGD. This study was approved by the SingHealth Centralised Institutional Review Board (reference no. 2016/2620) and the Singapore University of Technology and Design Institutional Review Board (reference no. 15-088). RESULTS Twenty individuals participated in five FGDs. Majority were male (65.0%), Chinese (55.0%), had at least a pre-university education level (70.0%) and resided in public flats (55.0%). We identified five main themes and 12 subthemes [Figure 1 and Table S1, see Supplemental Digital Appendix at https://links.lww.com/SGMJ/A21].Figure 1: Themes and sub-themes from the analysis.Theme 1: The need for continuity of care Sub-theme 1.1: Availability of past medical records Some participants felt that the availability of documented medical records and the health provider's knowledge of their condition influenced them to choose GPs instead of A&E. Sub-theme 1.2: The type of doctor–patient relationships Some participants chose GPs because they had a positive doctor–patient relationship and valued the familiarity with their regular doctor. Some of them highlighted that they were likely to seek treatment from a healthcare provider with whom they had previous experience. "I went to my nearest uh GP, is also my family doctor because I know she have the records of my family including my children so in terms of bonding wise, patient and doctor. [The GP] knows what happening too. She got the case so I prefer uh GP rather than to A&E."—(ID35) Theme 2: Patient-perceived quality of care Sub-theme 2.1: Presence of specialists and medical expertise at A&E to handle various medical conditions Most participants expressed confidence in A&E as a place with the medical expertise to handle a variety of medical cases. "Because they [A&E] have a lot of experience I assumed, all sorts of situations? I meant most, I would assume that most GPs mostly see the standard flu and cough. But if it is something more out of the ordinary, then I would trust A&E rather than the GP."—(ID15) Sub-theme 2.2: Comprehensive medical facilities and expertise provided in one place The availability of onsite ancillary services (e.g. X-rays, blood tests) offered participants a sense of assurance that they would be able to receive the required quality of care for their condition. They regarded the lack of such ancillary facilities in the GP clinic, coupled with the unavailability of same-day test results, as reasons for choosing A&E over GPs. "The reason I would go to A&E rather than a GP is because uh, I think the A&E can give me my blood test results, X-Ray, everything. It's like a one-stop thing. As for GP, you need to wait for a few days, at least one day you know, before you know what's happening in the blood test."—(ID23) Theme 3: Patient-perceived severity of medical condition Sub-theme 3.1: Perceived severity of condition influences the health-seeking behaviour. Participants explained that they would head straight to A&E if they perceived their conditions to be severe. Sub-theme 3.2: Urgency to seek medical assurance and relief from pain and discomfort Participants expressed the urgency for immediate medical attention to allay their concerns over the uncertainty of their condition's severity and to be relieved from pain and discomfort as soon as possible. "If I deem my condition requires immediate attention and I want quick, quick answers you know. Because the main worry is you want to know what's the cause of it, is it something very life threatening or I mean you get an assurance lah, and answers straightaway. I will go to A&E."—(ID31) Sub-theme 3.3: Reliance on different information sources for judgement of severity Participants were aware that A&E is meant for urgent conditions and reported seeking health information from multiple sources, such as friends and family members, printed materials, personal experiences and the internet, to determine their condition's severity and the choice of healthcare provider. "Based on the situation and based on our life experience. And our knowledge, judge. So the two examples I have given for myself just now, the hernia ok, is not so important, must have it done immediately. Unless great pain. Burst! But I know my situation not, so is not necessary to go to A&E. Alright, the hand so swollen and getting worse, I think I have to go to A&E, especially the finger is already twisted."—(ID11) Theme 4: Minimising out-of-pocket (OOP) cost Sub-theme 4.1: Various forms of medical coverage that improves healthcare affordability Participants mentioned that their entitlement to company medical benefits, insurance coverage or financial assistance enticed them to seek care at providers where they could claim for their medical bills and save costs. "…the MSF (Ministry of Social and Family Development) helping me. They give me a card and say that in this 6 months, I don't have to pay anything if I go for medical lah. Then in that case I go to A&E… then I can get the free medicine lah."—(ID22) Sub-theme 4.2: Costs incurred from seeking treatment at GPs Participants expressed the fear of being charged twice if they were referred to A&E after visiting a GP. Moreover, participants felt that GP fees are costly, especially after-hours, and any additional treatment or tests ordered would charged separately. "Like at night, you go to the 24 hours GP clinic, you pay even more and after that they say you have to go to the A&E immediately. So with the letter you go the A&E and you pay another set of fees."—(ID23) Sub-theme 4.3: Willingness to endure longer wait times for lower OOP costs Some participants preferred lower OOP costs even if they had to endure longer waiting times. "Hmm… For me ah, lower cost. [Interviewer: So it doesn't matter how long you have to wait] No."—(ID13) Theme 5: Minimising time to access care Sub-theme 5.1: Minimising waiting time to medical consultations Participants highlighted a need to be attended to by the respective healthcare providers in the shortest time possible. Individuals who chose to consult GPs did so due to perceived shorter waiting. "I don't like to wait uh because when I sick and I have to wait for hours at A&E, I rather go to the GP and get information and they straight away tell me what I am suffering from."—(ID64) Sub-theme 5.2: Time wasted before receiving appropriate care Primary care visits which preceded referrals to A&E were deemed as time consuming by most participants, and they disliked the idea of navigating through channels like hospitals' hotlines for information on where to seek treatment. "And if I go [primary care] and I wait and I, I… in the end I still get referred to the A&E, I must (might as) well go straight to A&E."—(ID31) DISCUSSION The analysis of the FDGs revealed five themes: the need for continuity of care; patient-perceived quality of care; patient-perceived severity of medical condition; minimising OOP cost; and minimising time to access care. Continuity of care is defined as the patient's experience of a smooth and coherent progression of care.[32-35] Typically, this requires a relationship between providers and patients that is based on trust and familiarity.[33,34] The findings of our study were consistent with those published in literature, whereby a positive physician–patient relationship is reported as one of the factors influencing the choice of GPs over A&E.[36-39] Also, previous positive experiences were positively associated with future choices of the same type of provider.[40,41] Hence, building a positive relationship between patients and their GPs could encourage patients to first seek treatment from GPs for non-urgent conditions. Patients who perceived their conditions to be severe preferred to visit A&E, which was deemed to provide better reassurance.[38,39,42-47] Nevertheless, there is evidence noting that patients were not always able to accurately assess their condition's severity,[38,46-48] highlighting a potential need for interventions. Previous educational campaigns in Singapore resulted in a decline of up to 67.3% for non-urgent A&E visits;[14] however, this effect wore off subsequently.[14] To mitigate this tapering effect, tapping on GP staff for word-of-mouth dissemination, launching regular health literacy and publicity awareness campaigns and the use of digital outreach methods[49] for IT-savvy adults could be considered. Better onsite ancillary services and medical specialists at A&E and minimising OOP cost and time to access care have been regarded as key contributing factors for non-urgent A&E visits.[20,21,37,39,43,50-52] Northington et al. observed that non-urgent A&E visits were driven by a belief that A&Es are better equipped to provide better quality of care compared to GPs.[20] Individuals who were financially insured for A&E visits contributed to increased non-urgent A&E usage.[45,53] In some cases, A&E was preferred over primary care providers, as no upfront payment was required.[39] Thus, policymakers could consider improving access to ancillary services and redesigning the financial coverage structure for GPs to incentivise visits to GPs first. Long wait times for GP appointments was a contributing factor for A&E visits in other studies.[21,39,54-56] We posit that this will be absent from our findings, as these studies were conducted in countries where the primary care system operates on a by-appointment-only model. Singapore's primary care facilities accept walk-ins,[57] thus removing the need to wait for an appointment. Despite a longer waiting time at A&E, some participants still preferred to proceed to A&E first, as they perceived it to be of better value in terms of convenience and cost-saving. This is a unique finding that was not mentioned by other qualitative studies.[15,37,38] Hence, to further examine such trade-offs, a discrete choice study could be designed to explore and quantify how certain attributes are valued over others. This study is not without its limitations. We did not recruit participants who were non-English speaking. This may limit the ethnic-specific perspectives that could potentially surface during FGDs. Bias arising from analysis of the data is possible, as the first author was the only coder and no inter-rater coding was performed; also, member checking[58] was not performed as we did not have access to participants' contact details. Therefore, the generalisation of results to other groups should be done with caution. In conclusion, the present study showed that multiple reasons influenced an individual's choice of healthcare provider. Therefore, a multipronged approach involving tailored regular outreaches, enhancement of the patient–GP relationship and provision of financial coverage might be effective in reducing A&E non-urgent cases in a multi-ethnic Asian population. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

OBJECTIVES:Pre-COVID-19 pandemic, patients who attended the emergency department (ED) for upper respiratory tract infection (URTI) were more likely to receive antibiotics if they expected them. These expectations could have changed with the change in health-seeking behaviour during the pandemic. We assessed the factors associated with antibiotics expectation and receipt for uncomplicated URTI patients in four Singapore EDs during the COVID-19 pandemic. METHODS:We conducted a cross-sectional study on adult patients with URTI from March 2021 to March 2022 in four Singapore EDs and assessed the determinants of antibiotics expectation and receipt using multivariable logistic regression models. We also assessed the reasons patients expect antibiotics during their ED visit. RESULTS:Among 681 patients, 31.0% expected antibiotics while 8.7% received antibiotics during their ED visit. Factors (adjusted odds ratio [95% confidence interval]) that significantly influenced expectation for antibiotics include: 1) prior consultation for current illness with (6.56 [3.30-13.11]) or without (1.50 [1.01-2.23]) antibiotics prescribed; 2) anticipation for COVID-19 test (1.56 [1.01-2.41]); and 3) poor (2.16 [1.26-3.68]) to moderate (2.26 [1.33-3.84]) knowledge on antibiotics use and resistance. Patients expecting antibiotics were 10.6 times (10.64 [5.34-21.17]) more likely to receive antibiotics. Those with tertiary education were twice (2.20 [1.09-4.43]) as likely to receive antibiotics. CONCLUSION:In conclusion, patients with URTI who expected antibiotics to be prescribed remained more likely to receive it during the COVID-19 pandemic. This highlights the need for more public education on the non-necessity for antibiotics for URTI and COVID-19 to address the problem of antibiotic resistance.

INTRODUCTION Computed tomography (CT) is increasingly used in the management of patients with nontraumatic abdominal pain at the emergency departments (EDs) in Singapore and Asia. While this is an established practice in many Western countries, the value of this approach remains unknown in most Asian public hospitals. As healthcare is often heavily subsidised in these hospitals, there are valid concerns about whether CT scan of abdomen and pelvis (CTAP) is a viable and financially sustainable strategy in the ED. We conducted a retrospective review of CTAP for nontraumatic abdominal pain performed in our ED with the following objectives: To examine the indications for ordering the ED CTAP To determine the rate of positive and negative ED CTAP To quantify the cost and impact on the length of stay (LOS), using acute appendicitis as a proxy, for ED CTAP To ascertain the utility of ED CTAP in assessing geriatric patients with abdominal pain. METHODS Our hospital is a public teaching hospital in Eastern Singapore with a daily average ED attendance of approximately 430 patients. Our ED charges a fixed attendance fee of SGD120 (USD1 = SGD1.33). In addition, the Ministry of Health reimburses the ED another SGD186 for each patient (subvention). The total amount of SGD306 per ED attendance is meant to cover the costs of laboratory tests, simple plain film radiological investigations, medications and treatment, but not CT scans in the ED. Instead, the costs of ED CT scans are to be borne by the patients. Patients who do not wish or are unable to bear the costs of ED CT scans may choose to be admitted, thus allowing their payments to be covered by private hospitalisation insurance or MediSave. Medisave is a government-mandated national medical savings scheme, in which individuals set aside between 8% and 10.5% of their income in a medical-focused savings account, which can then be used to pay for their personal or approved dependents' hospitalisation, day surgery and certain outpatient expenses, and their healthcare needs in old age. An anonymised de-identified electronic database of all ED patients who had ED CTAPs done in 2020 was created. We excluded CTAP for trauma, CT aortograms and CT intravenous urograms, as these are dedicated scans indicated for specific conditions. Relevant data, including demographic information, indications for CTAP, CT scan reports, ED diagnoses, disposition from ED, costs and LOS in both ED and wards, were captured. A specialist emergency physician (EP) must approve the CT scans ordered in the ED. ED CTAPs were reviewed by radiologists on duty and their conclusions were considered the final diagnoses. For comparison of the costs and time taken to surgery for patients who had their CTAP done in the ED versus in the wards, we reviewed patients with a diagnosis of acute appendicitis, as this is a common indication for CTAP. The time to surgery (starting from ward admission), gross bill sizes and the LOS were recorded for both populations. We used the Mann–Whitney U test for comparison analysis. We also compared our data with previous overseas papers evaluating similar ED utilisation of CTAPs. These included reviews on the appropriateness of utilisation, negative rates of scanning and usage in the elderly population. A waiver of consent for this study was approved by the institutional ethics review committee. RESULTS In 2020, 1,860 patients (56% male) underwent CTAP in the ED for nontraumatic abdominal pain. The mean age of the patients was 50 years (range 14–99), with 365 (19.6%) patients aged >70 years and 9 (0.5%) patients aged 14–16 years. The mean LOS in the ED was 5.2 h (range 1.37–26.83 h). When we analysed the indications for ordering a CTAP [Table 1], the top six indicators were right upper and lower quadrant pains, flank pains, left lower quadrant pain, persistent abdominal pain despite observation after analgesia, and suspicion for intestinal obstruction (clinical diagnosis with or without plain abdominal radiographs).Table 1: Indications for CTAP and the common diagnoses and disposition outcomes in ED patients. (N=1,860)We had a positive CT scan rate of 83.8% (1,558 out of 1,860 cases) with abnormal findings to explain the symptoms. The top ten ED diagnoses after CTAP for all ages are listed in Table 1. Acute appendicitis, biliary tract disease, renal stones, ovarian disease and bowel disease were the common conditions in the ED. About 16% of the CT scans revealed no abnormality to account for the symptoms. Indications for these cases were either nonspecific abdominal pain or sepsis of unidentified source with abdominal symptoms. When we analysed the geriatric patient group (≥70 years), the spectrum was similar, but 15 unsuspected basal pneumonia cases were diagnosed after being seen on the upper sections of the CTAP. Malignancies were less common diagnoses at 3% [Table 1], with bowel, gynaecological and hepatobiliary malignancies being the most prevalent. Almost 70% of the patients were admitted to inpatient wards. We referred 6.5% to a partner maternity hospital emergency clinic for urgent gynaecological conditions, thus avoiding 121 unnecessary admissions to our surgery department. We discharged 3.4% of patients who had a negative CTAP, and they neither reattended the ED within 72 h nor suffered any adverse outcomes. We could confirm some medical causes of abdominal pain only after a negative CTAP scan. Confirmed examples included 13 patients with basal pneumonia, eight patients with diabetic ketoacidosis, eight patients with mesenteric lymphadenitis and one patient with dengue [Table 1]. In Table 2, the time to CTAP, surgery, LOS (calculated from the time of ward admission) and the gross bill sizes for patients admitted with appendicitis are shown. Patients who underwent ED CTAPs had significantly faster time to a scan and surgery, lower bill sizes and shorter LOS. This was after adjusting (by exclusion) for 18 patients with confounding comorbidities (dementia, myocardial infarction, heart failure, renal failure, chronic pulmonary disease) that led to prolonged stays.Table 2: Time to computed tomography (CT) and surgery, bill size and length of stay for appendicitis patients.DISCUSSION Our ED installed a CT scanner initially in the late 2000s for assessing polytrauma and stroke patients. By the early 2010s, CTAPs were performed for patients with nontraumatic abdominal pain. This strategy was in response to access block from increasing demands for beds in our hospital. It was also to arrive at a faster diagnosis to avoid complications from acute surgical conditions. Initially, the costs of performing CTAPs in the ED were absorbed by the hospital if the patient was not admitted. Under a fixed fee of SGD306 for each emergency attendance, this meant a substantial loss for the hospital as each CTAP costs about SGD700 (standard nonsubvention rate). After 2015, patients had to pay for ED CTAPs. It was decided that the cost would be at a cost recovery price of SGD350 (priced at 50% less than the standard SGD700). Should the CTAP show a condition that necessitated emergency admission, the cost would be included in the inpatient bill instead of the ED charges. Patients could then choose to pay part or all of their hospitalisation bills with their own savings, private insurance or from MediSave. The average bill size for a one-day stay under surgery for subsidised wards is SGD1,215. This includes all cost drivers, procedure fees, operating theatre costs, medications, ward charges and others presubsidy. As such, this is still more expensive than the total cost of SGD656 for an ED consultation and CTAP scan. Our high positive CT scan rate of 83.8% allowed for timely definitive treatment after confirmation of diagnoses based on CT findings. Publications from Western and Japanese settings[1-4] have shown that CT for abdominal pain changes the leading diagnosis, increases diagnostic certainty and facilitates management decisions. This is so even for unstable patients after adequate resuscitation,[5,6] and the old description of the CT scan as being the 'tunnel of death' no longer applies as modern machines are faster with higher resolutions. Using appendicitis as a proxy, our results showed benefits for patients who underwent CT scans in the ED. Our department uses the Alvarado score to help define indications for ED CTAP in the right lower quadrant as part of a suspected appendicitis protocol. We had a shorter median LOS of 0.3 days, which was statistically significant when analysed by the Mann–Whitney test. For comparison, Sala et al.[3] found in their study that the average hospital stay was almost one day (22 h) shorter for patients in the CT group than for those in the control group, but this was not statistically significant. There are valid arguments that performing CT scans in the ED could prolong transit time through the ED, causing choke points in the ED. The counterargument is that with more access block, usage of CT scans could reduce unnecessary admissions and free up hospital beds that are in high demand. In our hospital, where the daily average bed occupancy often hovers above 95%, we favour the latter argument. Before the ED was equipped with the CT scanner, our EPs would base the decision for admission almost entirely on clinical grounds. For example, if a patient presents to the ED with fever, vomiting, anorexia and right lower quadrant rebound tenderness, with blood investigations showing an elevated white cell count that results in an Alvarado score of 8, most senior EPs would decide to admit the patient based on the rationale that even if the final diagnosis is not appendicitis, the condition will still likely warrant admission (e.g., diverticulitis, perforated colonic cancer, pyelonephritis, etc.). With the advent of ED CT scanning, the aforementioned approach to admit the patient based on the clinical status of the patient largely remains, even before the CT scan is fully reported or performed, so as to expedite the admission process. An urgent consultation or admission can then be obtained if the CT scan demonstrates a condition requiring urgent surgical intervention. A negative scan, on the other hand, may allow the patient to be discharged safely. This helps to mitigate the CTAP becoming a choke point for patients flowing through the ED. A literature review revealed that we were not alone in using this approach. In Toronto, Wang et al.[7] described three similar patterns of ED dispositions to improve admission efficiency: Disposition after the initial imaging report: the most common pattern where CTAP is performed and interpreted before the disposition decision (83% of their patients) Disposition before report: where a disposition decision is made before the availability of the first radiology report but after the scan has been performed Disposition before CT: where the disposition decision is made before the start of the CTAP (e.g., when the plain films show obstructed bowel, resulting in a decision to admit before a CTAP is ordered) With adoption of patterns B (7%) and C (6%), the Toronto team found that the ED LOS for pattern A (mean 10.4 h) was statistically significantly longer than those for pattern B (mean 8.1 h) and pattern C (mean 6.9 h). Unfortunately, our anonymised database did not capture a corresponding set of data based on the three patterns. As such, we could not make a similar comparison. Nevertheless, the overall mean ED LOS for our patients was 5.2 h. In a survey by Kirsch et al.[8] in an American setting, the adult CTAP utilisation rate ranged from 11.3% at age 20–29 years to 24.6% for those over 65 years. This was similar to our study findings — 305 (16.4%) scans were performed in patients aged 20–29 years and 478 (25.6%) in those over 65 years. In an evidence-based guideline developed by Gans et al.[9] (in a multispecialty Dutch collaboration), the decision for CT scans had to be complemented with good history taking and physical findings, supplemented with relevant laboratory investigations and ultrasound, to have high CTAP sensitivity and specificity. With a positive CT scan rate of 83.8% in our study population, we may now use this as a reference to monitor the trends in the usage of CT scans and avoid misuse. At the Mayo Clinic (an academic tertiary care setting), Bellolio et al.[10] performed a cross-sectional study of all ED visits that included CT scans between 2003 and 2012. Overall, CTAP use per 1,000 ED visits was between 55.4 in 2003 and 75.62 in 2012 (P < 0.001). In comparison, we had 15.4 CTAPs per 1,000 ED visits for 2020. Conversely, Choy and Yoon[11] conducted a study to predict negative scans in 300 ED patients aged ≤60 years who underwent ED CTAP. Their retrospective model predicted that a patient with normal white blood cell count and normal abdominal exam is 70.8% less likely to have a significant positive finding. Older patients often present with vague symptoms, unreliable physical findings and laboratory values may be altered by chronic organ disease. The morbidity and mortality associated with elderly abdominal pathological conditions are more significant.[12,13] We should, therefore, have a lower threshold for scanning. Our positive rate was 19.6% in this age group, which was lower than in American and European studies. Gardner et al.[12], in an American retrospective study of 464 patients (>80 years), found that CTAPs were positive in 55% of the patients, even with a disease spectrum similar to ours in the top ten conditions. Also, 43% of their diagnoses were clinically unsuspected before CT and had a significant influence on the clinical management and disposition, such as appropriate surgical admission and surgery. Millet et al.,[13] reported 30.3% acute unsuspected pathologies in a European cohort. In our study, 16.2% of CTAPs revealed no abnormality to account for the symptoms (259 patients with normal findings and 43 patients with sepsis and abdominal symptoms but normal CTAP). A negative CTAP is reassuring to both patients and EPs. Medical causes of acute abdominal pain (e.g., diabetic ketoacidosis, dengue) were also confirmed after a surgical abdomen was safely excluded. When we looked at the literature, we could not find many suitable similar retrospective studies for comparing the negative scan rates for CTAPs of the entire abdomen. One comparable study by Laméris et al.[14] had 183 out of 1,021 patients (18%) with a negative scan. Pickhardt and Nelson[15] had a negative CT diagnosis in 52.7% of all patients. As such, we opine that our rate was acceptable compared to international data. We wish to emphasise that clinical judgement is guided by validated scoring systems, in conjunction with testing and/or preliminary imaging. For instance, Stengel et al.[16] reported a high negative CT rate of 77% for acute appendicitis in 2,283 patients in a retrospective study, without mention of Alvarado scoring or basis for clinical decision. This study is not without limitations. Working with a retrospective de-identified database without reviewing patients' medical records, we were not able to evaluate other factors that could affect time to CTAP or ED LOS. These factors could include delayed development of physical signs, atypical presentations in the early stages, and patients' consideration of financial options, possible contrast allergy or the risk of contrast-induced nephropathy, and others. The database also did not capture the various time stamps required for the analysis of patients' transit time through the ED and inpatient wards. These include time of registration, time of triage, time and duration of consultation with the EP, time of admission and duration to initial assessment by the inpatient physician, and waiting time between the patient's consent for surgery and the actual time of surgery. In conclusion, we should allow the funding model for ED patients to accommodate the usage of ED CTAP scans in the diagnostic workup for nontraumatic abdominal pain, and encourage the availability of other resources necessary for ED CTAPs to remain accessible. This would facilitate timely definitive management and appropriate disposition of patients from the ED. Utilisation of CTAPs should be guided by clinical suspicion and protocols with oversight by EPs to improve their accuracy and avoid indiscriminate ordering. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Background:Understanding the long-term outcomes and disability-adjusted life years (DALY) after out-of-hospital cardiac arrest (OHCA) is important to understand the overall health and disease burden of OHCA respectively, but data in Asia remains limited. We aimed to quantify long-term survival and the annual disease burden of OHCA within a national multi-ethnic Asian cohort. Methods:We conducted an open cohort study linking the Singapore Pan-Asian Resuscitation Outcomes Study (PAROS) and the Singapore Registry of Births and Deaths from 2010 to 2019. We performed Cox regression, constructed Kaplan-Meier curves, and calculated DALYs and standardised mortality ratios (SMR) for each year of follow-up. Results:We analysed 802 cases. The mean age was 56.0 (SD 17.8). Most were male (631 cases, 78,7%) and of Chinese ethnicity (552 cases, 68.8%). At one year, the SMR was 14.9 (95% CI:12.5-17.8), decreasing to 1.2 (95% CI:0.7-1.8) at three years, and 0.4 (95% CI:0.2-0.8) at five years. Age at arrest (HR:1.03, 95% CI:1.02-1.04, p < 0.001), shockable presenting rhythm (HR:0.75, 95% CI:0.52-0.93, p = 0.015) and CPC category (HR:4.62, 95% CI:3.17-6.75, p < 0.001) were independently associated with mortality. Annual DALYs due to OHCA varied from 304.1 in 2010 to 849.7 in 2015, then 547.1 in 2018. Mean DALYs decreased from 12.162 in 2010 to 3.599 in 2018. Conclusions:OHCA survivors had an increased mortality rate for the first three years which subsequently normalised compared to that of the general population. Annual OHCA disease burden in DALY trended downwards from 2010 to 2018. Improved surveillance and OHCA treatment strategies may improve long-term survivorship and decrease its global burden. Funding:National Medical Research Council, Singapore, under the Clinician Scientist Award (NMRC/CSA-SI/0014/2017) and the Singapore Translational Research Investigator Award (MOH-000982-01).

BACKGROUND:Survival with favorable neurological outcomes is an important indicator of successful resuscitation in out-of-hospital cardiac arrest (OHCA). We sought to validate the CaRdiac Arrest Survival Score (CRASS), derived using data from the German Resuscitation Registry, in predicting the likelihood of good neurological outcomes after OHCA in Singapore. METHODS:We conducted a retrospective population-based validation study among EMS-attended OHCA patients (≥18 years) in Singapore, using data from the prospective Pan-Asian Resuscitation Outcomes Study registry. Good neurological outcome was defined as a cerebral performance category of 1 or 2. To evaluate the CRASS score in light of the difference in patient characteristics, we used the default constant coefficient (0.8) and the adjusted coefficient (0.2) to calculate the probability of good neurological outcomes. RESULTS:Out of 11,404 analyzed patients recruited between April 2010 and December 2018, 260 had good and 11,144 had poor neurological function. The CRASS score demonstrated good discrimination, with an area under the curve of 0.963 (95% confidence interval: 0.952-0.974). Using the default constant coefficient of 0.8, the CRASS score consistently overestimated the predicted probability of a good outcome. Following adjustment of the coefficient to 0.2, the CRASS score showed improved calibration. CONCLUSION:CRASS demonstrated good discrimination and moderate calibration in predicting favorable neurological outcomes in the validation Singapore cohort. Our study established a good foundation for future large-scale, cross-country validations of the CRASS score in diverse sociocultural, geographical, and clinical settings.

BACKGROUND:Older adults aged 65 years and above have a disproportionately higher utilization of emergency healthcare, of which Emergency Department (ED) visits are a key component. They experience higher degree of multimorbidity and mobility issues compared to younger patients, and are consequently more likely to experience a health event which requires an ED visit. During their visit, older adults tend to require more extensive workup, therefore spending a greater amount of time in the ED. Compared to the younger population, older adults are more susceptible to adverse events following discharge. Considering these factors, investigating the determinants of ED utilisation would be valuable. In this paper, we present a protocol for a systematic review of the determinants of ED utilisation among communitydwelling older adults aged 65 years and above, applying Andersen and Newman's model of healthcare utilisation. Furthermore, we aim to present other conceptual frameworks for healthcare utilisation and propose a holistic approach for understanding the determinants of ED utilisation by older persons.METHODS:The protocol is developed in accordance with the standards of Campbell Collaboration guidelines for systematic reviews, with reference to the Cochrane Handbook for Systematic Review of Interventions. Medline, Embase and Scopus will be searched for studies published from 2000 to 2020. Studies evaluating more than one determinant for ED utilisation among older adults aged 65 years and above will be included. Search process and selection of studies will be presented in a PRISMA flow chart. Statistically significant (p < 0.05) determinants of ED utilisation will be grouped according to individual and societal determinants. Quality of the studies will be assessed using Newcastle Ottawa Scale (NOS).DISCUSSION:In Andersen and Newman's model, individual determinants include predisposing factors, enabling and illness factors, and societal determinants include technology and social norms. Additional conceptual frameworks for healthcare utilisation include Health Belief Model, Social Determinants of Health and Big Five personality traits. By incorporating the concepts of these models, we hope to develop a holistic approach of conceptualizing the factors that influence ED utilisation among older people.SYSTEMATIC REVIEW REGISTRATION:This protocol is registered on 8 May 2021 with PROSPERO's International Prospective Register of Systematic Reviews (CRD42021253770).