Despite the fact that the 15 leading causes of global deaths and disability-adjusted life years are from conditions amenable to emergency care, and that this burden is highest in low-income and middle-income countries (LMICs), there is a paucity of research on LMIC emergency care to guide policy making, resource allocation and service provision. A literature review of the 550 articles on LMIC emergency care published in the 10-year period from 2007 to 2016 yielded 106 articles for LMIC emergency care surveillance and registry research. Few articles were from established longitudinal surveillance or registries and primarily composed of short-term data collection. Using these articles, a working group was convened by the US National Institutes of Health Fogarty International Center to discuss challenges and potential solutions for established systems to better understand global emergency care in LMICs. The working group focused on potential uses for emergency care surveillance and registry data to improve the quality of services provided to patients. Challenges included a lack of dedicated resources for such research in LMIC settings as well as over-reliance on facility-based data collection without known correlation to the overall burden of emergency conditions in the broader community. The group outlined potential solutions including incorporating data from sources beyond traditional health records, use of standard clinical forms that embed data needed for research and policy making and structured population-based research to establish clear linkages between what is seen in emergency units and the wider community. The group then identified current gaps in LMIC emergency care surveillance and registry research to form a research agenda for the future.

Objectives: This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.Methods: This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.Results: In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.Conclusions: ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.ACADEMIC EMERGENCY MEDICINE 2015;22:1025-1033 by the Society for Academic Emergency Medicine C are at the emergency department (ED) is usually focused on acutely ill patients facing life-threatening conditions. Worldwide, EDs have faced problems of overcrowding, long patient wait times, and admission bed blocks related to increasing numbers of patients.1-7 ED visits in Singapore's seven public hospiFrom the Duke-NUS Graduate

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We found variation in the EMS systems across the eight Asia-Pacific countries/regions studied. The findings will inform the construction of a multinational Asia-Pacific research network for future comparative studies and could serve as a model for international research networks.

Known heart disease independently predicted poorer post-OHCA survival. This study may provide information to guide future prospective studies specifically looking at family education for patients with heart disease and the effect on OHCA outcomes.

Objectives:Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care.Methods:The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied.Results:The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created.Conclusion:Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options.

Objective: To assess the knowledge and attitudes of local primary health care physicians in relation to cardiopulmonary resuscitation (CPR) and defibrillation. Methods: We conducted a survey on general practitioners in Singapore by using a self-administered questionnaire that comprised 29 questions. Results: The response rate was 80%, with 60 of 75 physicians completing the questionnaire. The average age of the respondents was 52 years. Sixty percent of them reported that they knew how to operate an automated external defibrillator (AED), and 38% had attended AED training. Only 36% were willing to perform mouth-to-mouth ventilation during CPR, and 53% preferred chest compression-only resuscitation (CCR) to standard CPR. We found those aged 50 years were more likely to be trained in basic cardiac life support (BCLS) (P  0.001) and advanced cardiac life support (P = 0.005) or to have ever attended to a patient with cardiac arrest (P = 0.007). Female physicians tended to agree that all clinics should have AEDs (P = 0.005) and support legislation to make AEDs compulsory in clinics (P  0.001). We also found that a large proportion of physicians who were trained in BCLS (P = 0.006) were willing to perform mouth-to-mouth ventilation. Conclusion: Most local primary care physicians realize the importance of defibrillation, and the majority prefer CCR to standard CPR.

Background The COVID-19 pandemic has prompted hospitals to respond with stringent measures. Accurate estimates of costs and resources used in outbreaks can guide evaluations of responses. We report the financial expenditure associated with COVID-19, the bed-days used for COVID-19 patients and hospital services displaced due to COVID-19 in a Singapore tertiary hospital. Methods We conducted a retrospective cost analysis from January to December 2020 in the largest public hospital in Singapore. Costs were estimated from the hospital perspective. We examined financial expenditures made in direct response to COVID-19; hospital admissions data related to COVID-19 inpatients; and the number of outpatient and emergency department visits, non-emergency surgeries, inpatient days in 2020, compared to preceding years of 2018 and 2019. Bayesian time-series was used to estimate the magnitude of displaced services. Results USD$41.96 million was incurred in the hospital for COVID-19 related expenses. Facilities setup and capital assets counted for 51.6% of the expenditure; patient-care supplies comprised 35.1%. Out of the 19,611 inpatients tested for COVID-19 in 2020, 727 (3.7%) had COVID-19. The total inpatient- and ICU-days for COVID-19 patients in 2020 were 8,009 and 8 days respectively. A decline in all hospital services were observed from February following a raised disease outbreak alert level; most services quickly resumed when the lockdown was lifted in June. Conclusion COVID-19 has led to increase in healthcare expenses and displacement in hospital services. Our findings are useful for informing economic evaluations of COVID-19 response and provide some information about the expected costs of future outbreaks.