Managing COVID-19, the Singapore way

Singapore was one of the first countries to be affected by the COVID-19 pandemic. In this issue of the journal, we are privileged to be able to share the insights of Tan et al, who report on their response in a Paediatric Emergency Department in Singapore. The issue of personal protective equipment (PPE) has been widely covered in the media and causes considerable anxiety to healthcare workers on the front line. In this manuscript, we can learn from the risk-based approach taken by this department in Singapore, dividing the Emergency Department into high, intermediate and low risk areas. Staff working in higher risk environments were given a greater level of PPE. The report gives some valuable insights into how this department handled the pandemic, taking a pragmatic approach to PPE based on the risk posed within a certain environment, rather than the intended nature of a particular patient encounter.

How prepared are we to provide end of life care in the ED?

In these challenging times, it has never been more important for us to be well prepared to provide end of life care in the ED. The COVID-19 pandemic has forced many emergency physicians to make rapid decisions about the goals of care within minutes of patients arriving in the ED. We have a disease with no recognised treatment, and many of its victims have a considerable burden of chronic disease, dependency and low physiological reserve.

It is therefore very pertinent that we have three papers devoted to the issue of end of life care in the ED. Mughal et al report a systematic review of qualitative studies evaluating barriers to providing end of life care in the ED. They identify important issues with regard to the availability of training, appropriate guidelines and ask whether the environment in our EDs is truly fit for purpose with regard to the provision of end of life care. Meanwhile, Wright et al have evaluated the impact of a training course on end of life care for emergency physicians, designed by experts in palliative care.

Finally, our Associate Editor, Mary Dawood, has also given her expert insights into this issue in a practice review. This is a must-read for all of us working in the ED, covering how to communicate effectively with patients and relatives, the appropriate use of ‘do not attempt resuscitation’ orders and the importance of establishing goals of care, while also covering such important issues as how to support relatives and how best to address the issue of organ donation.

Optimising the use of early warning scores

We have also published three fascinating pieces on the use of early warning scores in this issue. First, the evidence to back use of the Paediatric Observation Priority Score (POPS) has been accumulating in recent times. In this issue, Bonfield et al evaluated the interobserver reliability of POPS, reporting satisfyingly favourable results. Finnkin et al reported the relationship between the National Early Warning Score (NEWS) of patients assessed in primary care and referral to the ED. It may seem unsurprising that the vast majority of patients had low NEWS scores. You may be more surprised, however, to discover how many patients with high NEWS scores were not referred to the ED.

Finally, Vihonen et al evaluated whether the prognostic value of NEWS could be improved in the pre-hospital setting by also taking account of blood glucose. Interestingly, it could.

Emergency medicine training in Africa

Finally, for the many people who have an interest in global health, Akomeah et al report on the variation in Emergency Medicine training programmes across Africa. It was no doubt challenging to collate this information, but the findings will be very valuable to gauge our progress in developing the specialty in Africa in coming years.

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