Introduction: Supraventricular tachycardia (SVT) is commonly encountered in the emergency department (ED). Vagal manoeuvres are internationally recommended therapy in stable patients. The head down deep breathing (HDDB) technique was previously described as an acceptable vagal manoeuvre, but there are no studies comparing its efficacy to other vagal manoeuvres. Our objective in this study was to compare the rates of successful cardioversion with HDDB and the commonly practiced, modified Valsalva manoeuvre (VM). Methods: We conducted a randomised controlled trial at an acute hospital ED. Patients presenting with SVT were randomly assigned to HDDB or modified VM in a 1:1 ratio. A block randomisation sequence was prepared by an independent biostatistician, and then serially numbered, opaque, sealed envelopes were opened just before the intervention. Patients and caregivers were not blinded. Primary outcome was cardioversion to sinus rhythm. Secondary outcome(s) included adverse effects/complications of each technique. Results: A total of 41 patients were randomised between 1 August, 2018–1 February, 2020 (20 HDDB and 21 modified VM). Amongst the 41 patients, three spontaneously cardioverted to sinus rhythm before receiving the allocated treatment and were excluded. Cardioversion was achieved in six patients (31.6%) and seven patients (36.8%) with HDDB and modified VM, respectively (odds ratio1.26, 95% confidence interval, 0.33, 4.84, P = 0.733) . Seventeen (89.5%) patients in the HDDB group and 14 (73.7%) from the modified VM group did not encounter any adverse effects. No major adverse cardiovascular events were recorded. Conclusion: Both the head down deep breathing technique and the modified Valsalva manoeuvre appear safe and effective in cardioverting patients with SVT in the ED.

Singapore was one of the earliest countries affected by COVID‐19, outside China. EDs in Singapore faced a surge of confirmed cases of COVID‐19 patients, which stretched their resources. Here we describe how we adopted strategic changes using the identify‐isolate‐inform tool to improve the evaluation, treatment and management of COVID‐19 patients. During this pandemic, information technology integration, modifications to the electronic medical record and essential enhancements to the dashboard were implemented in a timely manner to match the clinical needs. Considerations for an isolation facility within an ED are especially important for future outbreaks.

Background: Emergency Department (ED) crowding is a global public health issue with low-acuity ED attendances (LAA) being widely identified as contributors to the issue. A primary care partnership programme, GPFirst, was developed to encourage low-acuity patients to visit their General Practitioners (GP) first, instead of the ED. We utilised a qualitative approach to gain an understanding of participants’ perceptions of GPFirst, their health-seeking behaviours, and explore recommendations for enhancing GPFirst. Methods: A qualitative study design, underpinned by an interpretivist approach, was employed. Purposive sampling was used to recruit 12 GPFirst patients from a single tertiary care centre for semi-structured interviews. These interviews were analysed using Braun and Clarke’s reflexive thematic analysis. Results: Participants’ age ranged from 25 to 63 years old. Four themes were identified. Firstly, “ perceptions of GPs”, described the variations in participants’ perceptions about GPs. Secondly, “patients’ expectations of GPFirst”, noted the ED fee subsidy and prioritisation of ED care as key expectations of GPFirst. Thirdly, “facilitators and barriers to utilising GPFirst” highlighted the facilitators and barriers that influenced participants’ health-seeking behaviours and finally “recommendations for programme improvement” offered strategies for improvements. Conclusion: This is the first qualitative study to examine participants’ perceptions of GPFirst. Recommendations may inform future programme redesign to optimise patient experience and facilitate programme uptake, contributing to overall efforts to reduce ED crowding locally. Future research may consider exploring GPFirst providers’ perspectives to elicit facilitators and barriers in implementation.

South Korean studies on coronavirus disease-2019 (COVID-19) treatment have described the use of community treatment centers (CTCs), which combine elements of the home and hospital, to isolate and treat mild COVID-19 patients. While the number of South Koreans diagnosed with COVID-19 cases has varied greatly by season, the number of confirmed cases in foreign nationals has shown no seasonality, with an average of around 25 to 30 per day. For foreign patients, accommodation arrangements and travel routes may be difficult; they may also have difficulty accessing medical care, so require careful management. We discuss our experience in operating and managing a CTC for foreign COVID-19 patients arriving in South Korea with mild symptoms. We also propose guidelines for efficient use of resources with respect to treating these patients in CTCs. We present the clinical findings of patients treated at the CTC between 7 October and 22 November 2020, and make some recommendations. We quarantined and treated foreign patients with mild symptoms of COVID-19 at the Ansan CTC. Discharge is determined based on clinical symptoms rather than polymerase chain reaction results. Medical and administrative staff use building A, while building B is used for isolating patients. Medical rounds are in the form of twice-daily video calls. Three kinds of foods with medication are served according to the patient's country of origin. In total, 315 patients were admitted to the Ansan CTC between 7 October and 22 November 2020; 145 of them were discharged from the CTC and 26 were transferred to other hospitals. To utilize medical resources efficiently during the pandemic, it is desirable to reserve CTCs exclusively for foreign patients.

Background: Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. Objective: We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. Methods: Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians’ antibiotic prescribing rate compared with the departments’ overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. Results: We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. Conclusions: Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore’s national effort to tackle antimicrobial resistance and can be scaled up if successful. Trial Registration: ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836

Background: GPFirst is a primary care partnership program designed to encourage patients with nonurgent conditions to seek care at participating general practitioner clinics instead of visiting the emergency department. In 2019, a digital media campaign (DMC) was launched to raise awareness and knowledge about GPFirst among residents in eastern Singapore. Objective: This study aims to assess the DMC’s impact on awareness and knowledge of GPFirst across different age groups, and the acceptability and satisfaction of GPFirst. Methods: The DMC, comprising Facebook posts and a website designed using the Andersen behavioral model, was evaluated through 2 repeated cross-sectional surveys. The first cross-sectional survey (CS1) was conducted with eastern Singapore residents aged 21 years and older, 2 1 year before the campaign’s launch, and the second survey (CS2) 4 months after. Satisfaction was measured on a 5-point Likert scale (very poor to excellent) about GPFirst experiences. Acceptability was assessed with 3 yes or no questions on decisions to visit or recommend GPFirst clinics. Analyses used tests of proportions, adjusted multiregression models, and age-stratified secondary analyses. Results: The Facebook posts generated 38,404 engagements within 5 months, with “#ThankYourGP” posts being the most viewed (n=24,602) and engaged (n=2618). Overall, 1191 and 1161 participants completed CS1 and CS2 respectively. Compared to CS1, CS2 participants were more aware (odds ratio [OR] 2.64, 95% CI 2.11-3.31; P<.001) and knowledgeable of GPFirst (OR 4.20, 95% CI 2.62-6.73; P<.001). Awareness was higher among married individuals (OR 1.31, 95% CI 1.04-1.66; P=.03), those without a regular primary care physician (OR 1.79, 95% CI 1.44-2.22; P<.001), and with higher education levels. Similarly, knowledge was greater among individuals with secondary (OR 2.88, 95% CI 1.35-6.17; P=.006) and preuniversity education (OR 2.56, 95% CI 1.14-5.70; P=.02), and those without a regular primary care physician (OR 1.54, 95% CI 1.02-2.34; P=.04). For acceptability, among participants who visited a GPFirst clinic, 98.2% (163/166) reported they would continue to visit a GPFirst clinic before the emergency department in the future, 95.2% (158/166) would recommend the clinic, 60.2% (100/166) cited the clinic’s participation in GPFirst as a factor in their provider’s choice and 87.3% (145/166) were satisfied with GPFirst. Among those unaware of GPFirst, 88.3% (1680/1903) would consider visiting a GPFirst clinic before the emergency department in the future. Conclusions: The DMC improved awareness and knowledge of GPFirst, with high satisfaction and acceptability among participants. Age-dependent strategies may improve GPFirst participation. The “#ThankYourGP” campaign demonstrated the potential of user-generated content to boost social media engagement, a strategy that international health systems could adopt.