Healthy Living 123 (Since 2007) 健康生活123: S’pore hospitals need to address root cause of bed crunch, not just add more beds and staff https://www.straitstimes.com/singapore/hospitals-need-to-address-root-cause-of-bed-crunch-not-just-add-more-beds-and-staff

S’pore hospitals need to address root cause of bed crunch, not just add more beds and staff

https://www.straitstimes.com/singapore/hospitals-need-to-address-root-cause-of-bed-crunch-not-just-add-more-beds-and-staff

2022-12-04

The Straits Times

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S’pore hospitals need to address root cause of bed crunch, not just add more beds and staff

Salma Khalik

Senior Health Correspondent

The shortage of beds is nationwide problem, affecting most private hospitals too. PHOTO: ST FILE

Published

4 Dec 2022, 5:00 am SGT

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SINGAPORE - “Bed shortages at public hospitals are not new, though rarely have they been this bad – with some patients waiting more than two days to get one.”

Sounds familiar? This was run in The Straits Times (ST) in January 2014.

That was neither the first time, nor the last, the newspaper highlighted the tight bed situation in the public sector leading to long waits for beds.

Some of the measures implemented to tackle bed crunch situations in the past included placing beds along the corridor at Tan Tock Seng Hospital (TTSH), Khoo Teck Puat Hospital (KTPH) squeezing three patients into a cubicle meant for one in the emergency department, and a tent set up outside Changi General Hospital’s (CGH) emergency department to house spillover patients waiting for a bed in a ward.

During those years, the private sector also helped out, as it is doing now. But rarely has the situation been as bad as it is now, with some patients waiting four to five days for a bed after a doctor says they need to be hospitalised.

Today, the shortage of beds is a nationwide problem, affecting most private hospitals too, with some needing to turn away patients for the lack of beds or operating theatres.

Measures taken to ease the current situation include getting people with serious but not urgent medical conditions to postpone surgery. But this will merely push the problem further down the line.

Health Minister Ong Ye Kung has announced that more hospitals are being built and more nurses are being recruited – another 1,900 hospital beds in the next five years, and 4,000 more nurses by the end of 2023.

That will certainly ease the situation – but for how long?

The bed crunch in 2010 was eased with the opening of KTPH that year. Despite the addition of more than 500 beds by KTPH, the situation started getting stretched a year later. By 2013, public hospitals were again short of beds. This was eased with the opening of Ng Teng Fong General Hospital (NTFGH) in 2015, followed by Sengkang General Hospital (SKH) in 2018.

But it’s bed crunch time yet again. While it is true that the current crunch has been exacerbated by the Covid-19 pandemic, the high demand for beds is not going to disappear with the pandemic, going by previous experience.

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A query by ST to the three public healthcare clusters and the Ministry of Health (MOH) on what is being done to improve the situation shows that everyone appears to be working harder, but not differently.

Professor Terrance Chua, group chairman of the medical board for the SingHealth cluster, which runs Singapore General Hospital (SGH), CGH and SKH, said its hospitals are “performing more ambulatory procedures so that some patients can be discharged safely from the hospital without being admitted, and deferring some non-urgent elective surgery and admissions”.

Professor Lim Tock Han, group chairman of the medical board for the National Healthcare Group, which runs TTSH and KTPH, said: “Beds are made available by promptly and safely discharging or transferring medically fit patients to suitable facilities such as short-stay facilities for patients whose conditions are less urgent but would still require close clinical monitoring for a short period of time; community hospitals; transitional care facilities; or Covid-19 treatment facilities.

“Discharge takes place both on weekdays and weekends.”

Both clusters also said that care of patients is started in the emergency department for those waiting for a space in a ward, and staff are also redeployed to help out, should there be a need.

Professor Quek Swee Chye, acting group chairman of the medical board for the National University Health System, said 18 beds at NTFGH meant for day surgery patients are now used for inpatients.

The National University Hospital has added a new inpatient facility with 16 beds, but this is a temporary arrangement till the first quarter of 2023.

Prof Quek added: “More basic-care assistants have been recruited to support ward nurses to care for patients who require assistance with activities of daily living. Locum nurses have also been brought in to support patient care at the emergency department.”

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Fortunately, the number of patients at the emergency department fell significantly in November – to fewer than 16,000 a week from as high as more than 17,700 in October. If this continues, it should give hospitals a bit of a breather.

Still, a more permanent solution is needed. It cannot and should not just be a matter of building more hospitals and recruiting more staff – though they, too, are necessary. If hospitals continue working the same way, given Singapore’s rapidly ageing population, even more hospital beds, doctors and nurses would be needed beyond what has been currently planned.

Aside from the number of hospital beds and medical staff, the age and health of the population, the ability to treat patients outside of hospitals, and other social and financial factors all play a part.

The number of patients at an emergency department fell significantly in November – to less than 16,000 a week from as high as more than 17,700 in October. ST PHOTO: ALPHONSUS CHERN

Do all patients need to be hospitalised?

In the past, hospitals had come up with out-of-the-box solutions when confronted with overwhelming patient numbers. The hospital heads realised that not all patients in their wards actually needed to be there.

Some sacred healthcare cows were slaughtered.

The changes included getting patients going for surgery to arrive at the hospital on the day of the operation, instead of checking in a day earlier so they could clear their bowels and be prepared for surgery. Patients could, and most preferred to, do this at home. This move saved hundreds of bed-days each year.

Another is turning more operations into day surgery, so patients could go home the same day without needing to spend a night or two at the hospital. But this was possible only when subsidies and insurance were aligned so patients did not have to pay more out of pocket as a result.

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TTSH also sent medical teams to nearby nursing homes to treat patients, to reduce their need to be admitted to hospital. For these frail patients, the trip to the hospital could worsen their condition, and they usually ended up spending more time in a ward than younger patients, occupying much-needed beds.

Oncologist Choo Su Pin said recently that not all cancer patients who turn up at the emergency department need to be hospitalised. Some could be treated as outpatients.

The same is probably true of a number of patients who go to the emergency department because their illness has taken a turn for the worse, and they or their families are concerned.

However, such a judgment call may require a specialist and, depending on when the patient shows up at the emergency department, there may not be any available because it is the middle of the night or during the weekend.

Is this something that can be worked out? Perhaps have a specialist on call who can, through telemedicine consultation, decide if a patient needs to be admitted, or if he could be given medication and an appointment at a relevant clinic the next day?

Better yet, could primary care catch health problems before they become too severe, so people can be treated as outpatients rather than needing hospital care?

Similarly, could home care, including home hospice care, be expanded so fewer patients need to go to hospital for treatment? While this may ease the demand for hospital beds, it will not reduce the number of medical professionals needed to care for patients.

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Ageing population

An ageing population generally places a heavier burden on healthcare, and Singapore’s population is rapidly ageing. Furthermore, older people tend to stay longer when they are admitted to hospital.

The move to foster a Healthier SG initiative may go some way towards reducing the need for medical treatment by keeping more people healthier for longer. But it will be years, if not decades, before results are seen.

Meanwhile, Singapore is expecting one in four people here to be 65 years and older by 2030, up from just under one in five today.

Of course, 65 years is not a magic number when people tip over to become unhealthy. But it is used as a proxy to show the expected growth in healthcare demand.

In 2020, when 15.2 per cent of the resident population was aged 65 and older, these seniors accounted for 34 per cent of all admissions to an acute hospital, and 72 per cent of admissions to a community hospital.

Singapore obviously needs a new model of care, fast. As the number of older people increases substantially, the demand for hospital beds will likely go up in tandem – if we merely continue doing things the same way.

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Getting patients out fast

Just like getting patients to arrive on the day of surgery to save hundreds of bed-days, getting them out of hospital as soon as they recover is equally important to free up beds for patients waiting to be admitted.

Acknowledging this, SingHealth’s Prof Chua said: “The timely discharge of patients from our hospital wards plays an important role in managing waiting time and alleviating the demand for bed spaces. In general, patients who are deemed medically fit to leave the hospital will be assessed and discharged accordingly throughout the week.”

One bottleneck occurs when a patient’s family asks for him to remain an extra day or two for a variety of reasons, including needing time to find a full-time carer for the patient.

Fewer discharges also tend to occur over the weekend as most senior doctors would not be around to certify that the patient is fit to go home.

An MOH spokesman said the ministry is working with the Agency for Integrated Care and hospitals to facilitate more discharges during weekends, but added: “Generally, fewer patients are discharged on Saturdays and Sundays as fewer patients are admitted towards the end of the week.”

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What is ideal?

Hospital beds are expensive, so it doesn’t make sense to have many empty beds on standby. Singapore has also been cautious about any oversupply of hospital beds, as more beds could encourage more patients to remain longer in hospital.

On the other hand, having too few hospital beds could be detrimental to the health of the population. Singapore has been lauded for its public healthcare system. But if the tight bed situation continues, or recurs every few years in spite of more hospitals being built, the quality of healthcare will suffer.

In March, Senior Minister of State for Health Janil Puthucheary said hospitals ideally should have occupancy rates of less than 85 per cent. “Sustained bed occupancy rates above the 85 per cent threshold may increase the risk of poor clinical outcomes due to the reduced access to hospital care,” he said.

Having an occupancy rate of 85 per cent does not mean that 15 per cent of beds in the hospital are available to the next patient. Some of them are specialised, such as in the intensive care or high dependency wards, or are for children. Or they may be isolation beds kept on standby should a patient with a highly infectious disease be admitted.

Private hospitals, for which the bottom line is important, generally prefer an occupancy rate of below 80 per cent so they would not need to turn away patients. So 85 per cent would appear to be the ceiling for hospitals to provide the best care for patients.

But few public hospitals have been able to achieve an occupancy rate consistently below 85 per cent. In April, Health Minister Ong said the overall average monthly occupancy rate of the 9,728 beds in public hospitals was 88.5 per cent. Some of the busier hospitals have occupancy rates almost consistently above 90 per cent, and occasionally even 100 per cent.

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This crunch has spilled over into a situation called “exit block” at emergency departments – where patients who have been given emergency treatment remain for hours or even days in the emergency department because there are no beds available in the wards.

Unlike some countries, Singapore does not have a national target of how soon patients need to be attended to in the emergency department – critical cases are attended to immediately, but less urgent ones may have a longer wait – or how long they can be left in the emergency department, which is meant for emergencies and is far from ideal for patients waiting to be transferred to a ward.

There have been stories of patients remaining in the emergency departments for days, with no access to shower facilities. Also, unlike wards that dim the lights at night, emergency departments are always bright, noisy and usually cold.

It’s not an ideal situation for someone who is sick and needs peace and quiet. In some cases, this could worsen their condition, leading to an even longer stay in hospital.

Healthy Living 123 (Since 2007) 健康生活123

Monday, December 5, 2022

S’pore hospitals need to address root cause of bed crunch, not just add more beds and staff https://www.straitstimes.com/singapore/hospitals-need-to-address-root-cause-of-bed-crunch-not-just-add-more-beds-and-staff

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