Bee Hoon Heng

Forecasting daily attendances at an emergency department to aid resource planning

BackgroundAccurate forecasting of emergency department (ED) attendances can be a valuable tool for micro and macro level planning.MethodsData for analysis was the counts of daily patient attendances at the ED of an acute care regional general hospital from July 2005 to Mar 2008. Patients were stratified into three acuity categories; i.e. P1, P2 and P3, with P1 being the most acute and P3 being the least acute. The autoregressive integrated moving average (ARIMA) method was separately applied to each of the three acuity categories and total patient attendances. Independent variables included in the model were public holiday (yes or no), ambient air quality measured by pollution standard index (PSI), daily ambient average temperature and daily relative humidity. The seasonal components of weekly and yearly periodicities in the time series of daily attendances were also studied. Univariate analysis by t-tests and multivariate time series analysis were carried out in SPSS version 15.ResultsBy time series analyses, P1 attendances did not show any weekly or yearly periodicity and was only predicted by ambient air quality of PSI > 50. P2 and total attendances showed weekly periodicities, and were also significantly predicted by public holiday. P3 attendances were significantly correlated with day of the week, month of the year, public holiday, and ambient air quality of PSI > 50.After applying the developed models to validate the forecast, the MAPE of prediction by the models were 16.8%, 6.7%, 8.6% and 4.8% for P1, P2, P3 and total attendances, respectively. The models were able to account for most of the significant autocorrelations present in the data.ConclusionTime series analysis has been shown to provide a useful, readily available tool for predicting emergency department workload that can be used to plan staff roster and resource planning.

Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction

Background The world is short of 7.2 million health–care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource–limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students’ satisfaction and attitudes towards eLearning. Methods We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health–related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students’ knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach. Findings Forty–nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases. Conclusions Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage.

Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore

Between 1 and 22 March 2003, a nosocomial outbreak of Severe Acute Respiratory Syndrome (SARS) occurred at the Communicable Disease Centre in Tan Tock Seng Hospital, Singapore, the national treatment and isolation facility for patients with SARS. A case-control study with 36 cases and 50 controls was conducted of factors associated with the transmission of SARS within the hospital. In univariate analysis, contact with respiratory secretions elevated the odds ratio to 6.9 (95 % CI 1.4-34.6, P= 0.02). Protection was conferred by hand washing (OR 0.06, 95% CI 0.007-0.5, P=0.03) and wearing of N95 masks (OR 0.1, 95% CI 0.03-0.4, P=0.001). Use of gloves and gowns had no effect. Multivariate analysis confirmed the strong role of contact with respiratory secretions (adjusted OR 21.8, 95 % CI 1.7 274.8, P=0.017). Both hand washing (adjusted OR 0.07, 95 % CI 0.008-0.66, P=0.02) and wearing of N95 masks (adjusted OR 0.1, 95% CI 0.02-0.86, P=0.04) remained strongly protective but gowns and gloves had no effect.

Analysis of Factors Causing Long Patient Waiting Time and Clinic Overtime in Outpatient Clinics

This paper is focused on the factors causing long patient waiting time/clinic overtime in outpatient clinics and how to mitigate them using discrete event simulation. A two-week period of data collection is conducted in an outpatient clinic of a Singapore government hospital. Detailed time study from patient arrival to patient departure is conducted, and the possible factors causing long patient waiting time/clinic overtime are discussed. A discrete simulation model is constructed to illustrate how to improve the clinic performance by mitigating the detected factors. Simulation and implementation results show that significant improvement is achieved if the factors are well addressed.

Asymptomatic SARS Coronavirus Infection among Healthcare Workers, Singapore

We conducted a study among healthcare workers (HCWs) exposed to patients with severe acute respiratory syndrome (SARS) before infection control measures were instituted. Of all exposed HCWs, 7.5% had asymptomatic SARS-positive cases. Asymptomatic SARS was associated with lower SARS antibody titers and higher use of masks when compared to pneumonic SARS.

Self-reported chronic diseases and health status and health service utilization - Results from a community health survey in Singapore

ObjectiveTo report the extent of self-reported chronic diseases, self-rated health status (SRH) and healthcare utilization among residents in 1-2 room Housing Development Board (HDB) apartments in Toa Payoh.Materials & methodsThe study population included a convenience sample of residents from 931 housing development board (HDB) units residing in 1-2 room apartments in Toa Payoh. Convenience sampling was used since logistics precluded random selection. Trained research assistants carried out the survey. Results were presented as descriptive summary.ResultsRespondents were significantly older, 48.3% reported having one or more chronic diseases, 32% have hypertension, 16.8% have diabetes, and 7.6% have asthma. Median SRH score was seven. Hospital inpatient utilization rate were highest among Indian ethnic group, unemployed, no income, high self-rated health (SRH) score, and respondents with COPD, renal failure and heart disease. Outpatient utilization rate was significantly higher among older respondents, females, and those with high SRH scores (7-10).ConclusionsThe findings confirming that residents living in 1-2 room HDB apartments are significantly older, with higher rates of chronic diseases, health care utilization than national average, will aid in healthcare planning to address their needs.

Predictors of frequent attenders of emergency department at an acute general hospital in Singapore

Objective To determine factors associated with frequent emergency department (ED) attendance at an acute general hospital in Singapore. Method Patients who attended the ED from 1 January to 31 December 2006 without prior attendance in the preceding 12 months (index attendance) were tracked for 12 months. Variables included in the analysis were age, gender, race, date and time of attendance, patient acuity category scale, mode of arrival, distance to ED and diagnosis based on ICD-9CM code. Frequent attenders were patients who attended the ED ≥5 times for any diagnosis within 12 months. Results A total of 82 172 patients in the study cohort accounted for a total of 117 868 visits within 12 months, of which 35 696 (30.3%) were repeat attendances. A total of 1595 patients (1.9%) were frequent attenders responsible for 8% of all repeat attendances. Stepwise logistic regression analysis found patients aged 75+ years, male, non-Chinese ethnic groups, Sunday and Monday, time of the attendance from 16:00 to midnight, distance to ED, chronic obstructive pulmonary disease, heart failure and acute respiratory infections to be significantly associated with frequent attendances. Conclusion With the ageing population and their complex healthcare needs, elderly patients with chronic medical conditions are expected to make up an increasing proportion of the workload of ED in the future. A systems approach and a disease and case management approach in collaboration with primary care providers are interventions recommended to stem this.

A comparison of comorbidities obtained from hospital administrative data and medical charts in older patients with pneumonia

BackgroundThe use of comorbidities in risk adjustment for health outcomes research is frequently necessary to explain some of the observed variations. Medical charts reviews to obtain information on comorbidities is laborious. Increasingly, electronic health care databases have provided an alternative for health services researchers to obtain comorbidity information. However, the rates obtained from databases may be either over- or under-reported. This study aims to (a) quantify the agreement between administrative data and medical charts review across a set of comorbidities; and (b) examine the factors associated with under- or over-reporting of comorbidities by administrative data.MethodsThis is a retrospective cross-sectional study of patients aged 55 years and above, hospitalized for pneumonia at 3 acute care hospitals. Information on comorbidities were obtained from an electronic administrative database and compared with information from medical charts review. Logistic regression was performed to identify factors that were associated with under- or over-reporting of comorbidities by administrative data.ResultsThe prevalence of almost all comorbidities obtained from administrative data was lower than that obtained from medical charts review. Agreement between comorbidities obtained from medical charts and administrative data ranged from poor to very strong (kappa 0.01 to 0.78). Factors associated with over-reporting of comorbidities were increased length of hospital stay, disease severity, and death in hospital. In contrast, those associated with under-reporting were number of comorbidities, age, and hospital admission in the previous 90 days.ConclusionsThe validity of using secondary diagnoses from administrative data as an alternative to medical charts for identification of comorbidities varies with the specific condition in question, and is influenced by factors such as age, number of comorbidities, hospital admission in the previous 90 days, severity of illness, length of hospitalization, and whether inhospital death occurred. These factors need to be taken into account when relying on administrative data for comorbidity information.

5-year survival and rehospitalization due to stroke recurrence among patients with hemorrhagic or ischemic strokes in Singapore

BackgroundStroke is the 4th leading cause of death and 1st leading cause of disability in Singapore. However the information on long-term post stroke outcomes for Singaporean patients was limited. This study aimed to investigate the post stroke outcomes of 5-year survival and rehospitalization due to stroke recurrence for hemorrhagic and ischemic stroke patients in Singapore. The outcomes were stratified by age, ethnic group, gender and stroke types. The causes of death and stroke recurrence were also explored in the study.MethodsA multi-site retrospective cohort study. Patients admitted for stroke at any of the three hospitals in the National Healthcare Group of Singapore were included in the study. All study patients were followed up to 5 years. Kaplan-Meier was applied to study the time to first event, death or rehospitalization due to stroke recurrence. Cox proportional hazard model was applied to study the time to death with adjustment for stroke type, age, sex, ethnic group, and admission year. Cumulative incidence model with competing risk was applied for comparing the risks of rehospitalization due to stroke recurrence with death as the competing risk.ResultsTotally 12,559 stroke patients were included in the study. Among them, 59.3% survived for 5 years; 18.4% were rehospitalized due to stroke recurrence in 5 years. The risk of stroke recurrence and mortality increased with age in all stroke types. Gender, ethnic group and admitting year were not significantly associated with the risk of mortality or stroke recurrence in hemorrhagic stroke. Male or Malay patient had higher risk of stroke recurrence and mortality in ischemic stroke. Hemorrhagic stroke had higher early mortality while ischemic stroke had higher recurrence and late mortality. The top cause of death among died stroke patients was cerebrovascular diseases, followed by pneumonia and ischemic heart diseases. The recurrent stroke was most likely to be the same type as the initial stroke among rehospitalized stroke patients.ConclusionsFive year post-stroke survival and rehospitalization due to stroke recurrence as well as their associations with patient demographics were studied for different stroke types in Singapore. Specific preventive strategies are needed to target the high risk groups to improve their long-term outcomes after acute stroke.

Economic impact analysis of an end-of-life programme for nursing home residents.

Background: Due to limited end-of-life discussions and the absence of palliative care, hospitalisations are frequent at the end of life among nursing home residents in Singapore, resulting in high health-care costs. Aim: Our objective was to evaluate the economic impact of Project Care at the End-of-Life for Residents in homes for the Elderly (CARE) programme on nursing home residents compared to usual end-of-life care. Design and settings/participants: Project CARE was introduced in seven nursing homes to provide advance care planning and palliative care for residents identified to be at risk of dying within 1 year. The cases consisted of nursing home residents enrolled in the Project CARE programme for at least 3 months. A historical group of nursing home residents not in any end-of-life care programme was chosen as the matched controls. Cost differences between the two groups were analysed over the last 3 months and final month of life. Results: The final sample comprised 48 Project CARE cases and 197 controls. Compared to the controls, the cases were older with more comorbidities and higher nursing needs. After risk adjustment, Project CARE cases demonstrated per-resident cost savings of SGD