This entry is meant to provide a broad perspective of what EDs in Singapore are currently facing.
Different hospitals may experience the following issues in varying degrees of severity.
Powers that be -*ahMOHem* - please take note.
10. Patient loads
An article in the ST today about the impending opening of KTPH helpfully highlighted the daily patient attendances at TTSH and CGH EDs, which now exceed 500.
SGH's numbers average 400-500, up from a tally of 300-400 just a couple of years ago.
Compared to many EDs overseas - even those in large cities - this is often double what many foreign institutions see.
Possible reasons?
9. Unnecessary referrals
Cases referred from polyclinics and GPs are of course inevitable. But one of my main grouses involves referrals for minor orthopaedic conditions which usually require no further treatment and may or may not warrant follow-up in the orthopaedic outpatient clinic.
Examples: minor toe or finger fractures - some of which were sustained more than a week ago -that do not require any intervention except oral painkillers and medical leave.
Such patients are ambulant and able to continue with daily activities with little difficulty, but chose to see the primary care physician because of persistent bruising or mild pain.
So the x-rays are done, a fracture is reported, the patient is told to come to the A&E and duly complies, only to have the ED doctor tell him/her that there's nothing more to be done really, and I'm sorry you have to fork out $80-$90 just to hear me say this.
I've had to endure a number of irate outbursts, not just because of the extra cost, but also due to time wasted waiting for hours at the ED.
Friends who work in the polyclinics tell me that all fractures MUST be referred to the A&E no matter what. Perhaps the protocol should be modified.
Other unnecessary referrals: patients with uncontrolled diabetes and hypertension who defaulted their meds but are otherwise symptom-free. Err, we already know why their glucose levels and blood pressure are high. So restart their meds, do a few baseline blood tests and review them in a few days. Reasonable, right?
The best one so far: a memo that asked the attending ED doctor to "please bring forward the patient's clinic appointment, which is 3 months away, and patient is very anxious because we're unable to arrange an earlier date."
Well okay, I suppose "anxiety" can be considered an "emergency" of sorts.
8. Self-referrals
Singaporeans are a savvy bunch, so walk-in cases are on the rise. It gets especially frustrating during office hours when you see a long list of upper respiratory tract infections and mild backaches / headaches / stomachaches in the ED, cases that could've been assessed by the primary physician and referred to us if necessary.
Our most loyal clientele? None other than NS boys. If you're referred by an SAF MO or turn out to have a real and acute medical / surgical condition, then the ED visit is certainly warranted.
But when you have a minor complaint and could've easily consulted your camp MO, or if you have a record of numerous ED visits and MC-seeking behaviour, and are observed to be laughing with your girlfriend while waiting to see the doctor, that really raises my hackles. Because you're just wasting our resources and lengthening the waiting times for other legitimate cases.
Note to the SAF: revise your policy regarding MC endorsement. How about assigning certain polyclinics or GPs to see these guys?
7. Long waiting times for Specialist Outpatient Clinic appointments
A chronic problem, now aggravated by an ever-increasing number of referrals from the A&E and primary care facilities.
We see symptomatic patients who come to the ED because they just couldn't wait any longer. Hernias get incarcerated or strangulated, chest pains turn into heart attacks, gastric ulcers perforate.
At my institution, cardiology appointments average 4-6 weeks ( that's even with an urgent A&E referral ). Some departments allow force-ins for urgent cases, but these are rare and based on good faith, so don't expect the ED physician to do this for every single patient who's anxious and insists on being fast-tracked.
6. Primary care in Singapore
I often ask myself if this is adequate, and the answer almost always comes back as a negative.
The polyclinics are overcrowded and understaffed. Medical officers see up to 80 patients in a 4-hour morning session which includes both simple and more complicated cases. Far from ideal.
GPs don't face such harrowing conditions, but it's common knowledge that many have turned to more profitable pursuits - e.g. aesthetics - because managing chronic illnesses and bread-and-butter stuff ( like coughs and colds ) simply can't sustain a practice.
Reason? An oversaturated GP market and paltry subsidies from the government, resulting in significantly higher fees which the patient himself has to bear.
So he either turns to the polyclinic, or comes straight to the A&E, not just to bypass the long waiting time at the former, but to enjoy a flat fee ( less than $100 ) at the latter, which includes x-rays, blood tests, standard medications, even a specialist review in the ED that very same day if indicated.
Most EDs now also offer observation protocols for various conditions - e.g. chest / abdominal pain, asthma, stable head injury - allowing the use of Medisave funds for treatment and specialized tests such as CT scans.
Compared to the GP clinic, which may charge a couple of hundred bucks just for x-rays and bloods alone ( and which the patient has to pay for out of his own pocket ), it's a steal.
And let's not forget the standing policy that all SOC referrals from GPs are considered paying class, so patients are charged B1/A class rates when they attend these clinics ( including investigations and procedures ). Only polyclinic and ED referrals enjoy subsidized rates.
Something for MOH to consider changing?
That said, I also hope our family physicians will spare a thought for the stressed-out ED doctor at the other end of their referrals. Surely a memo that says only "Giddiness ( or chest pain, headache etc ), please manage", with no other details about the patient's symptoms, physical findings, vital signs or treatment already instituted, can be construed as unprofessional? Even the polyclinic MOs can do better than this.
On the flip side, a posting with a well-established ( and pretty famous ) GP during the 4th year of medical school opened my eyes to the possibilities of running such a practice. This enthusiastic doctor conducted treadmill tests for his patients with chest pain, right there in one of his consultation rooms! He also did minor surgical procedures like abscess drainage. It still amazes me to this day.
5. Waiting times for admissions vs lodgers
I'm not familiar with any specific time-frame for lodgers, but my personal definition is "a patient awaiting ward admission, who still has no bed allocated after 2 hours".
2 hours because that's when the ward MO covering the ED is activated to come down and clerk the case, as per international JCI standards.
The admission process is a tedious one. Contrary to what many people think, it doesn't involve the simple click of a button and presto, you've got a bed!
First, the ED doctor books a bed by entering data fields in the patient's computerized records. The most pertinent info would be which department you're admitting to, and the ward class.
This triggers a cascade of events, where the Bed Management Unit is alerted and starts hunting for a suitable location. If there isn't one available, the case is highlighted as "lodger" status.
When certain departments' designated "mother wards" fill up, subsequent admissions start to overflow to other wards.
But the main hiccup occurs when the hospital runs out of beds in a certain class - most commonly B2 - and the BMU starts assigning B1 or even A class beds to these patients.
I've worked at 4 different public hospitals ( wards as well as EDs ) in my lifetime, and can tell you that there's a significant difference between institutions where parking B2 patients in higher class wards is concerned.
One has no qualms about putting C class patients in A class rooms ( a huge bonus for the lucky ones ), while others balk at the notion, and refuse to allocate these wards despite the availability of beds.
Timing of admissions can also be a key factor. Whether it's politically correct or not to comment on this, I feel it's pertinent to the delay in transferring ED patients upstairs, so it should be mentioned.
It's no secret that ward nurses refuse to accept transfers during shift changes because they're "passing report", but this is acceptable up to a certain extent. There're instances where a 2-hour period is completely blocked off - i.e. 1 hour before and 1 hour after the actual shift change. If it's a seriously ill patient who doesn't qualify for ICU care, the case will inevitably take up one cubicle in the resus room, with at least 1 doctor and a couple of nurses tied up with monitoring him/her continuously.
And considering how EDs regularly juggle 5-6 critical cases at a time, not being able to send the patients to the wards can be extremely taxing on the A&E staff.
Sometimes, we're told the patients can't go up because someone was just discharged and they need to clean the bed. Inexplicably, this can take 3-4 hours to complete.
One institution has a strange system where the ward nurses have to click on something in the computer software before the patient can be sent up. So the nurses refuse to click on it so they don't have to accept the case. And it appears that nothing can be done even though everyone knows about the problem.
Is there a shortage of beds in public hospitals? You bet.
But are there other reasons for the EDs' lodger headaches? I'll leave it to our reporters to go do some digging.
4. Shortage of ICU / High Dependency beds
I've been experiencing this a lot at my workplace this past year.
Contributing factors:
a) many sick patients admitted from the A&E and also transferred from general wards after deteriorating acutely
b) a steady stream - or perhaps increasing number ( no official stats available ) - of elective admissions who also need ICU / HD care post-procedure
c) little expansion of ICU / HD facilities
The challenge lies in balancing the need to reserve beds for the electives ( which generate money ) vs the acute cases ( don't generate as much money and also occupy ICU / HD beds for longer periods ).
The first thing that certain institutions need to address is the space constraint. 5 HD and 10 ICU beds aren't enough for a huge discipline like Medicine.
So it isn't uncommon to have HD cases lodging in the ED for 12 hours, and ICU patients with nowhere to go when even the overflow ICUs are full.
3. Surge capacity
A reader asked if our healthcare system can cope in the event of a major disaster.
Of course not.
But this is a global problem, so Singapore has nothing to be ashamed of.
I've participated in a number of mass casualty exercises. While useful in theory, I have my doubts about its application in a more realistic setting.
Who will be hit the hardest should such an event occur? Unquestionably, the A&E.
Based on personal experience, I would give the following estimates as the threshold for an ED's breaking point:
a) minor casualties: up to 50
b) major casualties ( requiring some form of resuscitation or urgent intervention ): 20
Once, I was on shift during a mini-mass casualty incident involving inhalation of fumes from an unknown gas. 11 casualties arrived at the ED - 1 major ( Priority 1 ), 10 minor ( but still classified as Priority 2 ). It took me 4 hours to manage the major case, and another 2 doctors the entire shift to clear the minors.
The incident occurred on a busy Monday afternoon.
If a disaster hits during peak hour and casualties number in the hundreds or thousands, WE ARE DEAD.
Sorry, just stating a fact, no matter how unpleasant it may be.
2. Managing patients' expectations
Think I may have discussed this in a previous entry, but as you can see, it remains an important issue and still doesn't receive the attention it deserves.
The culprits responsible for patients' unreasonable demands haven't changed much - the media, referring doctors, our own Health Minister ( remember his comment about how all ED cases will be "seen immediately"? ) - and I can only surmise that nobody reads the local papers since we get no sympathy despite all the articles highlighting bed shortage, patients abusing hospital staff and what-not.
If there's ever an opportunity for me to design a brochure stating the A&E's many limitations ( be prepared to wait if it's busy; no MRI, no MIBI / echo / Holter, no treadmill, no gastro- or colonoscope; looooong clinic appointment waiting times; no fancy-shmancy meds like Nexium and COX-II inhibitors; no specialist consultant to come down to see you so be satisfied with the MO okay? ), I volunteer my services.
1. Manpower
My biggest grouse, and the root of many of our difficulties.
Why we need to bulk up:
a) patient attendances are rising steadily
b) EDs are doing more for patients - observation protocols, investigations, procedures, etc. These take time and slow the queues down if there aren't enough staff
c) patients are also getting sicker - more staff are required to manage such cases
d) the residency programme is starting - with clear guidelines that restrict the number of patients residents are allowed to see during a shift, absolute MO numbers are no longer accurate gauges of sufficient manpower
e) more foreign-trained doctors in the ED - they need more time to adjust, have different learning curves, face language barriers and are generally less productive than the locals. So again, absolutely numbers don't mean much.
f) more junior MOs in the ED - we no longer turn away 1st posting MOs, and A&E is not compulsory for medical and surgical trainees ( it used to be about 10 years ago ). Inexperienced doctors require much closer supervision and work at a slower rate. Put 3 of them together during a busy shift and you'll understand what I mean.
g) more doctors and nurses needed during night shifts - aside from the warranted cases, I see quite a few patients ( mostly foreign workers ) who come in the middle of the night just because they clock in 12-hour days and the clinics are closed when they finish work. So now the A&E is a glorified poly- / GP clinic eh?
The New York Times' interview of Dr Peter Pronovost was just emailed to me. He is a US anesthetist (John Hopkins Hospital) who has done remarkable work both as researcher and activist for patient safety. He is perhaps most famous for having drastically reduced the rates of central venous catheter infections in both his own institution as well as participating hospitals in the state of Michigan via a simple checklist (and not some fancy expensive drug-coated catheter or futuristic robotic insertion technique).
The final part of the interview is particularly interesting. When asked how patients could protect themselves from hospital errors, he mentioned that patients should have a clear idea of the hospital's infection rate. If this was high or the hospital did not track its infection rate, the patient should go elsewhere. Patients should also be their own advocates and ask if healthcare staff have washed their hands, or if their venous catheters were necessary. These last bits are very tough for local patients (or their relatives), but I have worked in public hospitals in Singapore - and these conversations are necessary to move things forward.
Sometimes - perhaps tragically - it takes a prominent foreigner to publicly state unpleasant truths about Singapore. Dr Francoise Barre-Sinoussi, 2008 Nobel laureate for her work as a co-discoverer of HIV in 1983, expressed strong criticism of the way HIV was tackled in Singapore when she came for a visit 2 weeks ago. Her comments were published by BusinessWeek among other news agencies, and of course, mentioned in local websites. In essence, she felt that the prevalence of HIV in Singapore was now somewhat higher than her own country France, and that "the stigma, the fact that they have to pay for everything, it's the worst conditions for stimulating people to be tested and treated".
MOH has replied in its usual way.
This matter is not new. Singaporean HIV activists and healthcare providers have long highlighted these issues to MOH but they have been stonewalled, brushed aside, and/or chastised, among other things.
The essence of the matter is that HIV care is comparatively substandard in Singapore, and this I should add is not really the fault of the healthcare providers. Baseline investigations, including viral load testing every half-year, are not cheap. Testing for viral resistance as is recommended by international guidelines? Research only. HIV drugs, as Stuart Koe and others have pointed out, are expensive mainly because generics cannot be legally imported and prescribed in Singapore. The cheapest HAART regimen in Singapore will set a patient back about SGD800.00 a month. If he/she requires second-line therapy, the cost rapidly escalates beyond SGD1,500.00/month. SGD550.00/month can be claimed from Medisave for the purchase of HIV drugs, and as of this year, Medifund has also been made available for HIV patients. Even if Medisave was inexhaustible, SGD250.00/month just for drugs is not trivial for the majority of HIV patients who are in the lower income bracket (or jobless).
The cost (to the patient) of HIV drugs in the developed world, parts of Africa, Cambodia, and even our neighbour Malaysia? Free... These are not the foolish and impractical actions of socialistic governments, but rather, cold and hardheaded utilitarian policies.
What do most HIV patients in Singapore do? They turn to unofficial "buyers clubs" where generic HIV drugs are bought in Thailand and smuggled into Singapore at a cost of about SGD120.00/month. That such enterprises have existed for more than a decade and that MOH has had to turn a blind eye to them is the surest sign that the healthcare system has failed in this particular instance. Healthcare providers at CDC (Singapore, not Atlanta) try to help in other ways, like participating in industry-sponsored and international HIV treatment trials. Subjects enrolled into these trials can then receive standard-of-care therapy or trial drugs free for a limited time beyond the duration of the trials. None of these seem good or sustainable in the long term.
HIV is not a disease like cancer, diabetes or cardiovascular disease, even though with adequate treatment HIV patients will surely outlive most cancer patients (and have equivalent survival compared with the other two). It is transmissible, especially during the early and late phases of the infection, and therefore of considerable public health importance. MOH's response has been to ramp up testing (especially of males) but it has neglected the issues of social stigma and treatment costs. It is no wonder that relatively few people come forward for testing. Why should they when the benefits are outweighed by the considerable downsides of a positive test?
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