An eLearning program to prepare residents for a rotation in pediatric emergency medicine: A qualitative study

Background:

To meet ACGME-I (Accreditation Council for Graduate Medical Education–International) training and duty hour requirements, we converted our 3-week-long pediatric emergency medicine induction program to an eLearning program.

Objectives:

The study aimed to identify areas of the eLearning program residents perceived useful and the components that helped them prepare for clinical work.

Methods:

The qualitative study took place in a tertiary pediatric emergency department. Twenty-seven residents from family medicine, emergency medicine, and pediatric medicine participated in focus group discussions to explore how they perceived the eLearning program helped prepare them for work. The interviews were audio-recorded, and transcripts were analyzed and coded into categories and themes.

Results:

Four themes emerged from the data analysis: residents’ access to the eLearning program, instructional methods, eLearning design elements, and supplementary learning. Residents valued autonomy to control their pace of learning and use online features that matched their preferred learning styles. Design features such as the use of questions and quizzes helped stimulate learning, but attention had to be paid to the order of questions in the modules and the format of the questions. Written guidelines served as a good reference for learners and face-to-face sessions accompanying the eLearning program helped reinforce knowledge and offered opportunities to interact with faculty members to clarify questions.

Conclusion:

Systematic planning focusing on access, instructional methods, and design is essential when creating eLearning programs for residency training. eLearning programs can be enhanced by the incorporation of team-based learning and having accompanying written content to reference.

Paediatric emergency department attendances during COVID-19 and SARS in Singapore

Introduction: We evaluated the impact of public health measures on paediatric emergency department attendances during the COVID-19 and severe acute respiratory syndrome (SARS) outbreaks in Singapore. Methods: Between 1 January 2020 and 31 July 2020, we retrospectively reviewed paediatric emergency department attendances and admissions in a tertiary paediatric hospital in Singapore before and after a national lockdown to combat the spread of COVID-19 in Singapore. Hospital attendances and admissions were compared with data from a corresponding period in 2019 (1 January 2019 to 31 July 2019), as well as during and after the SARS outbreak (1 January 2003 to 31 December 2004). Results: Compared with a corresponding non-outbreak period, emergency department attendances decreased in line with nationwide public health measures during the COVID-19 and SARS outbreaks (2020 and 2003 respectively), before increasing gradually following lifting of restrictions, albeit not to recorded levels before these outbreaks. During the COVID-19 outbreak, mean daily attendances decreased by 40%, from 458 per day in January–July 2019, to 274 per day in January–July 2020. The absolute number of hospital inpatient admissions decreased by 37% from January–July 2019 (19,629) to January–July 2020 (12,304). The proportion of emergency department attendances requiring admission remained similar: 20% in January–July 2019 and 21% in January–July 2020. Conclusion: Nationwide public health measures in Singapore have had an impact on paediatric emergency department attendances and hospital inpatient admissions. Data from this study could inform planning and resource allocation for emergency departments in Singapore and internationally. Keywords: COVID-19, paediatric emergency department, public health measures, SARS

Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore

BACKGROUND

Coronavirus disease 2019 (COVID-19) has impacted the provision of health services in all specialties. We aim to study the impact of COVID-19 on the utilization of pediatric hospital services including emergency department (ED) attendances, hospitalizations, diagnostic categories and resource utilization in Singapore.

METHODS

We performed a retrospective review of ED attendances and hospital admissions among children < 18 years old from January 1st to August 8th 2020 in a major pediatric hospital in Singapore. Data were analyzed in the following time periods: Pre-lockdown (divided by the change in Disease Outbreak Response System Condition (DORSCON) level), during-lockdown and post-lockdown. We presented the data using proportions and percentage change in mean counts per day with the corresponding 95% confidence intervals (CIs).

RESULTS

We attended to 58,367 children with a mean age of 5.1 years (standard deviation, SD 4.6). The mean ED attendance decreased by 331 children/day during lockdown compared to baseline (p < 0.001), attributed largely to a drop in respiratory (% change - 87.9, 95% CI - 89.3 to - 86.3, p < 0.001) and gastrointestinal infections (% change - 72.4, 95%CI - 75.9 to - 68.4, p < 0.001). Trauma-related diagnoses decreased at a slower rate across the same periods (% change - 40.0, 95%CI - 44.3 to - 35.3, p < 0.001). We saw 226 children with child abuse, with a greater proportion of total attendance seen post-lockdown (79, 0.6%) compared to baseline (36, 0.2%) (p < 0.001). In terms of ED resource utilization, there was a decrease in the overall mean number of procedures performed per day during the lockdown compared to baseline, driven largely by a reduction in blood investigations (% change - 73.9, 95%CI - 75.9 to - 71.7, p < 0.001).

CONCLUSIONS

We highlighted a significant decrease in infection-related presentations likely attributed to the lockdown and showed that the relative proportion of trauma-related attendances increased. By describing the impact of COVID-19 on health services, we report important trends that may provide guidance when planning resources for future pandemics.

Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department

Singapore was one of the earliest countries affected by the coronavirus disease 2019 (COVID-19) pandemic, with more laboratory-confirmed COVID-19 cases in early February 2020 than any other country outside China. This short report is a narrative review of our tertiary paediatric emergency department (ED) perspective and experience managing the evolving outbreak situation. Logistic considerations included the segregation of the ED into physically separate high-risk, intermediate-risk and low-risk areas, with risk-adapted use of personal protective equipment (PPE) for healthcare personnel in each ED area. Workflow considerations included the progressive introduction of outpatient COVID-19 testing in the ED for enhanced surveillance; adapting the admissions process particularly for high-risk and intermediate-risk cases; and the management of unwell accompanying adult caregivers. Manpower considerations included the reorganisation of medical manpower into modular teams to mitigate the risk of hospital transmission of COVID-19. Future plans for a tiered isolation facility should include structural modifications for the permanent isolation facility such as anterooms for PPE donning/doffing; replication of key ED functions in the tent facility such as a separate resuscitation room and portable X-ray room; and refresher PPE training. Dynamic reassessment of ED workflow processes, in conjunction with the hospital and national public health response, may help in managing this novel disease entity.

Utility of Spatial Point-Pattern Analysis Using Residential and Workplace Geospatial Information to Localize Potential Outbreak Sources

Identifying the source of an outbreak facilitates its control. Spatial methods are not optimally used in outbreak investigation, due to a mix of the complexities involved (e.g., methods requiring additional parameter selection), imperfect performance, and lack of confidence in existing options. We simulated 30 mock outbreaks and compared 5 simple methods that do not require parameter selection but could select between mock cases’ residential and workplace addresses to localize the source. Each category of site had a unique spatial distribution; residential and workplace address were visually and statistically clustered around the residential neighborhood and city center sites respectively, suggesting that the value of workplace addresses is tied to the location where an outbreak might originate. A modification to centrographic statistics that we propose—the center of minimum geometric distance with address selection—was able to localize the mock outbreak source to within a 500 m radius in almost all instances when using workplace in combination with residential addresses. In the sensitivity analysis, when given sufficient workplace data, the method performed well in various scenarios with only 10 cases. It was also successful when applied to past outbreaks, except for a multisite outbreak from a common food supplier.

Parental knowledge and beliefs on the use of child car restraints in Singapore: a qualitative study

INTRODUCTION

Road traffic injuries and fatalities represent a significant public health problem. In Singapore, compliance with appropriate child car restraints (CCRs) is poor. We aimed to understand parental knowledge, beliefs and barriers regarding the use of CCRs.

METHODS

In this qualitative study, we conducted five focus group discussions with parents who drive with their children in private cars. Participants were recruited using the KK Women's and Children's Hospital's social media page. Guiding questions were derived by consensus following literature review and adaptation to the Singapore context, exploring parental perceptions of CCR use. Focus group interviews were then transcribed and analysed.

RESULTS

33 participants were recruited, with an age range of 28‒46 (mean age 35.5) years. They had a total of 46 children with ages ranging from 2.5 months to 14 years (mean age 4.2 years). Three key themes were identified: parental knowledge regarding CCRs, barriers to CCR use, and suggestions to increase CCR compliance. Barriers to compliance included lack of knowledge, difficult child behaviour and cultural norms. A multipronged approach was proposed to increase CCR use, including educating the public, reinforcing positive behaviour, legal enforcement as a deterrent to non-compliance, increasing CCR installation services, providing CCRs for taxi users and offering financial incentives.

CONCLUSION

Non-compliance to CCR use is multidimensional, including multiple potentially modifiable factors. This study could inform ongoing collaborative injury prevention efforts among healthcare professionals, industry partners and the traffic police, using public education and outreach to reduce the burden of road traffic injuries.

Road traffic injuries among children and adolescents in Singapore - Who is at greatest risk?

INTRODUCTION

Pediatric road traffic injuries remain a significant cause of death and disability in many countries in Asia, despite the implementation of road traffic safety laws. We aim to describe the injuries, the use of restraints among road users, and risk factors associated with severe injuries for children in Singapore.

METHODS

We performed a retrospective chart review of road traffic injuries presenting to the only two pediatric tertiary care hospitals in Singapore, from January 2012 to April 2016. We included children <16years old presenting to the emergency departments within 24h after injury (pedestrian, bicycle, motorcycle, motor vehicle). We calculated the frequencies for specific injury mechanisms, injury severity scores (ISS), and in-hospital outcomes of severe injuries (death, urgent resuscitation and emergent surgery). We performed a multivariate logistic regression to determine risk factors associated with severe injury.

RESULTS

There were 2468 patients during the study period. The mean age was 7.9 years (SD 4.7); 60.1% of road injuries involved motor vehicle occupants (1483/2468). Most bicyclist/motorcyclists were not wearing helmets (70.0%, 245/350) and 51.1% of motor vehicle passengers (758/1483) were not restrained. Compared to motor vehicle passengers, pedestrians (adjusted OR 2.38, 95% CI 1.41-3.99), bicyclists (adjusted OR 2.12, 95% CI 1.04-4.32) and motorcyclists (adjusted OR 6.09, 95% CI 2.04-18.24) were more likely to sustain severe injuries.

CONCLUSION

Child pedestrians, bicyclists and motorcyclists are especially vulnerable for severe injures. Further injury prevention efforts must focus on the enforcement of legislation to protect these high-risk groups.

A review of stroller-related and pram-related injuries to children in Singapore

Prams and strollers are commonly used in daily childcare. We aim to study the type and severity of injuries associated with prams and strollers in an Asian population. We performed a retrospective review of children below the age of 6 who presented to a tertiary paediatric hospital in Singapore, from January 2012 to June 2015, with such injuries. There were 248 pram-related and stroller-related injuries. The median age was 12.5 months old. 69 (27.8%) sustained open wounds, 17 (6.9%) suffered fractures or dislocations and 2 children had significant head injuries. 29 patients (11.7%) sustained injuries while on stairs or escalators. Most of the injuries (197 cases, 79.4%) occurred despite adult supervision. The need for intervention was associated with older age and entrapment injuries (p<0.001). Only appropriately sized prams and strollers without exposed hinges should be used. These should not be deployed on stairs and escalators.

Kids can't float: epidemiology of paediatric drowning and near-drowning in Singapore

INTRODUCTION

The aim of this research was to study the epidemiology of paediatric near-drowning and drowning victims in Singapore so as to determine the risk factors that will guide drowning prevention strategies.

METHODS

A total of 38 children aged 0-16 years, who were managed in the Emergency Departments of the Singapore Health Services network or the Department of Forensic Medicine, Health Sciences Authority, for drowning and near-drowning between February 2002 and January 2004, were surveyed as part of the Childhood Injury Surveillance Project. Data on demographics, the location of injury, environmental factors and injury particulars was collected by means of questionnaire forms, review of the in-patient records and the coroner's reports.

RESULTS

A total of 38 drowning or near-drowning cases in Singapore were reported during the study period, with nine deaths. The median age of the victims was 6.3 years. 52.6 percent of the incidents occurred in swimming pools. 60 percent of the swimming pools had a lifeguard on duty, and all the deaths that occurred in swimming pools were in those without a lifeguard. In 39.5 percent of the cases, no safety features were present at the site of the incident. Most of the deaths by drowning occurred in the sea (55.5 percent).

CONCLUSION

Deaths by drowning are preventable, and appropriate environmental redesign, legislation and public education are necessary to reduce the rate of paediatric drowning. The important factors that are lacking include the absence of pool fencing and lifeguards at swimming pools and recreational beaches.