Recently, the media has reported that emergency departments (EDs) at hospitals around Singapore have seen an influx in patients and increasingly long waiting times, leading to hospital bed crunch.
The issue was raised by nine Members of Parliament (MPs) on Nov. 8, and Health Minister Ong Ye Kung took the time to explain why EDs are facing a strain on resources, and what is being done to alleviate the crunch.
Ong first shared that as the Omicron Covid-19 variant is less dangerous than the previous Delta variant, pressure has shifted from the Intensive Care Unit in hospitals to the regular wards, and by extension, the EDs.
This shift is also caused by the increasing resilience of the Singapore population to the virus through vaccination.
While most people might feel that the pandemic is coming to a close, this is not true for healthcare workers and hospitals.
Ong pointed out that these workers are still experiencing heavy workloads despite the fact that "life has gone back to pre-Covid-19 normal" for most.
As Singapore treats the disease as endemic, the government has adopted three main public health measures against Covid-19:
- Safe management measures (SMMs) to reduce viral transmission;
- Vaccination so the infections do not translate into many cases, or severe illnesses and deaths, and;
- The healthcare system, which will treat and care for infected patients.
Considering that almost all SMMs have been removed and majority of Singaporeans have been vaccinated, "the burden of endemicity will fall disproportionately" on the healthcare system, Ong said.
He added that the heavy workload hospitals have been experiencing is thus, not a new issue.
"And that is why our wards and EDs have been very busy over the past year. The media highlighted that only recently but really our hospitals have been experiencing it for the whole year."
Highlighting the sacrifice and toil healthcare workers have undergone for so long, Ong pointed out that service levels may therefore drop, and waiting times might become longer, and urged Singaporeans to display appreciation and understanding towards the workers.
On waiting times at EDs
Ong went on to elaborate on the current situation at EDs.
He assured that priority goes to critically ill patients at EDs. For non-life threatening but emergency cases, the median waiting time across all EDs is around 20 minutes this year, which is "not a very long wait".
Emergency cases that require hospital admission is where the bottleneck lies — the median waiting time at EDs is around seven hours from January to September 2022. This is "a few hours longer than in 2019," Ong noted.
However, there are variations to this trend. When infection waves occur, waiting times can spike up to as high as 50 hours.
Nevertheless, Ong maintained that the hospitals will not compromise on the safety of patients.
"The current situation, make no mistake, is not sustainable, and we need to resolve it," Ong highlighted.
However, he shared that it has not been easy to solve this problem in the midst of the pandemic. Whenever an infection wave occurs, resources are diverted to "fight fire again".
Now that the Omicron XBB wave is subsiding, Ong emphasised the need to diagnose the operational bottleneck EDs are facing.
Mismatch in demand and supply of beds
Ong noted that the crowdedness at EDs and long waiting times are actually due to a mismatch in the demand and supply of hospital beds.
He cited figures which showed that the average monthly ED attendance, which translates to the demand for hospital beds, had decreased from 75,000 patients a month to 63,000 patients a month from 2019 to 2022.
This equates to a 16 per cent decrease in the daily attendance of patients over the two years.
In contrast, the proportion of patients at the ED that have serious conditions, require the most attention, and therefore most likely need hospital beds, increased by three per cent from 2019 to 2022.
This translates to an increase of several hundred patients a month, Ong cited.
At the peak of the Omicron wave and the recent Omicron XBB wave this year, there were an additional 600 Covid-19 patients at EDs each day, which is a 30 per cent increase in workload, potentially contributing to the demand for hospital beds.
There are also two factors constraining the supply of hospital beds and slowing down the process of warding ED patients, Ong explained.
Firstly, an ageing population has led to a rise in the number of patients with long stays at hospitals, reducing the turnover of hospital beds.
Secondly, construction delays due to the pandemic have delayed the opening of healthcare facilities such as the Woodlands Health Campus and the integrated care hub at Tan Tock Seng Hospital. These would have added a few hundred beds to the system had they opened in 2022 as planned.
Thirdly, hospitals are required to set aside or ring fence beds for the care of Covid-19 patients.
This is part of the healthcare system's emergency planning, and although there exists some flexibility in raising or lowering the number of ring fenced beds, it contributes to the hospital bed crunch and waiting times at EDs, Ong said.
He gave an analogy:
"Whether due to demand or supply factors, we need to recognise this. That is, we run a very high throughput hospital system. And in such a system, even a very small mismatch of demand and supply, a couple of 100 beds, will cause waiting times to spike up very significantly. You think of it that way, it's not very different from an expressway with very heavy traffic flow. All it needs is one branch fall on one lane or half a lane, and you have a massive traffic jam."
Two main adjustments
In order to resolve this problem, the Ministry of Health (MOH) will be making two structural adjustments, in addition to the slew of measures already in place to help hospitals cope.
More transitional care facilities (TCF) will be activated. Operated by private providers, these admit medically stable patients from public hospitals who are waiting for their transfer to intermediate or long term care facilities, or for their discharge plans to be finalised.
"It is therefore a very important step-down care facility to free up acute beds in hospitals," Ong said.
Public hospitals will work closely with TCF operators to do this.
The second adjustment involves moving away from ring fencing hospital beds exclusively for Covid-19 patients.
Now that most people have been vaccinated or have recovered safely from the virus, hospitals will be allowed to triage or assess their patients based on clinical severity and priority for treatment, and will not need to manage Covid-19 patients to a different standard.
Hospitals thus need not set aside whole wards for Covid-19 patients as a standard pandemic practice.
"This flexibility is important to a hospital to help them optimise the use of beds in a crunch situation," Ong added.
Ong concluded his speech by calling on Singaporeans to exercise social responsibility and self-test, and to see General Practitioners whenever possible instead of heading to EDs. Most importantly, people should keep their vaccinations up to date to prevent themselves from falling severely ill.
In response to Ong's speech, MP Yip Hon Weng questioned if there are enough healthcare workers for the TCFs, given the already tight manpower situation at hospitals.
Ong replied that this is an issue that can be solved in the short-term, by actively recruiting workers from overseas.
This recruitment process is already being carried out, since borders are opening up, and the ministry is also working with local institutions to bring in more healthcare workers.
Workers' Party MP Gerald Giam also suggested looking into providing more home support for patients, and helping families care for those who are suitable for discharge.
Ong responded that home discharge is a "major initiative" the ministry is looking at.
"So in a complex [healthcare] system like that, it's all of the above. Whether it's nursing home, step-down care, community hospital, home discharge, we look at all of them."
However, Ong noted that home discharge can be quite manpower intensive, as nurses will be required to visit the patients in their homes. On the other hand, more hospital beds will be freed up.
Home discharge is thus "a very important prong", and something that should be "discussed further".
Top photo from MCI and Zhangxin Zheng