Bed Capacity and Emergency Departments

NOTICE PAPER NO. 1488

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Mr Lim Biow Chuan

MP for Mountbatten

Question No. 3678

To ask the Minister for Health (a) whether the Ministry can carry out educational publicity to remind residents not to go to the accident and emergency departments of public hospitals except for genuine emergencies; and (b) whether the Ministry can encourage more clinics to operate on a 24-hours basis.

NOTICE PAPER NO. 1491

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Ms Joan Pereira

MP for Tanjong Pagar GRC

Question No. 3686

To ask the Minister for Health (a) what is being done to reduce the waiting time for (i) consultation at the Accident and Emergency Departments of public hospitals and (ii) ward beds at public hospitals; (b) whether the waiting time has reduced; and (c) if so, by how much.

NOTICE PAPER NO. 1493

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Mr Yip Hon Weng

MP for Yio Chu Kang

Question No. 3714

To ask the Minister for Health (a) whether an in-depth analysis is being done to identify the underlying causes of the hospital bed crunch problem; (b) how will hospitals ensure that care for patients in holding spaces, including those with non-critical issues, will not be compromised; (c) what mechanism is in place for the different healthcare clusters to forecast and raise the alarm about possible upward demand at emergency departments to make necessary arrangements in advance; and (d) when is the bed crunch expected to ease.

Question No. 3715

To ask the Minister for Health (a) with the activation of inpatient teams to help at emergency departments, whether this will cause other healthcare teams to be overworked; (b) where will the manpower for transitional care facilities (TCFs), particularly the TCF with 364 beds, come from; (c) how well-equipped are healthcare workers and aides in the step-down facilities to care for transferred patients; and (d) what are the immediate measures to expand our healthcare teams, considering that some services cannot be automated in the short-term.

NOTICE PAPER NO. 1493

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Mr Gerald Giam Yean Song

MP for Aljunied GRC

Question No. 3716

To ask the Minister for Health (a) what are the main reasons behind the long waiting times for admission at some restructured hospitals’ emergency departments in recent weeks; and (b) what are the measures the Ministry is taking to reduce waiting time especially for patients with higher acuity conditions.

NOTICE PAPER NO. 1494

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Dr Lim Wee Kiak

MP for Sembawang GRC

Question No. 3725

To ask the Minister for Health in light of the current hospital bed crunch (a) whether non-urgent elective surgeries in public hospitals will be postponed; (b) if so, whether this will once more result in a backlog after the current bed crunch is alleviated; and (c) how will the Ministry prevent the occurrences of deferring non-urgent treatments from turning into a vicious cycle of care backlog.

NOTICE PAPER NO. 1496

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON OR AFTER 8 NOVEMBER 2022

Name and Constituency of Member of Parliament

Ms Cheryl Chan Wei Ling

MP for East Coast GRC

Question No. 3751

To ask the Minister for Health (a) what are the critical bottlenecks in hospitals resulting in patients being held for long periods of time at emergency departments; (b) whether this has resulted in ambulances being unable to be deployed for other emergencies; and (c) what steps is the Ministry taking to more permanently resolve the lack of bed spaces in public hospitals.

NOTICE PAPER NO. 1498

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON OR AFTER 8 NOVEMBER 2022

Name and Constituency of Member of Parliament

Mr Murali Pillai

MP for Bukit Batok

Question No. 3767

To ask the Minister for Health (a) whether the risk of suffering from pressure injuries amongst bedridden patients who are kept for significant lengths of time at the accident and emergency departments of acute hospitals before being admitted to the wards is being monitored; and (b) whether such patients may be screened in advance for their susceptibility to develop pressure injuries and treated accordingly.

NOTICE PAPER NO. 1500

NOTICE OF QUESTION FOR ORAL ANSWER

FOR THE SITTING OF PARLIAMENT ON OR AFTER 8 NOVEMBER 2022

Name and Constituency of Member of Parliament

Ms Ng Ling Ling

MP for Ang Mo Kio GRC

Question No. 3771

To ask the Minister for Health whether the Ministry will consider developing a gate-keeping role and process at the polyclinics and GP clinics to reduce the number of patients whose conditions do not require emergency care at hospital emergency departments.

NOTICE PAPER NO. 1487

NOTICE OF QUESTION FOR WRITTEN ANSWER

FOR THE SITTING OF PARLIAMENT ON 7 NOVEMBER 2022

Name and Constituency of Member of Parliament

Ms Joan Pereira

MP for Tanjong Pagar GRC

Question No. 2336

To ask the Minister for Health whether the Ministry is working with private hospitals to ensure that these hospitals can step in to provide care to patients once our public hospitals reach a certain capacity limit and, if so, how.

NOTICE PAPER NO. 1508

NOTICE OF QUESTION FOR WRITTEN ANSWER

FOR THE SITTING OF PARLIAMENT ON OR AFTER 8 NOVEMBER 2022

Name and Constituency of Member of Parliament

Mr Liang Eng Hwa

MP for Bukit Panjang

Question No. 2399

To ask the Minister for Health (a) what are the projected increases in the number of hospital beds at private and public hospitals in the next five and 10 years respectively; and (b) how do these projections compare to the changes in the number of hospital beds at private and public hospitals five and 10 years ago.

Answer

1     Mr Speaker, with your permission, may I address questions 2 to 10 in today's Order Paper please?

2     Sir, during the Delta wave last year, our ICU wards came under immense pressure. This year, as we encountered the Omicron infection waves, the pressure shifted from the Intensive Care Unit (ICU) to regular hospital wards and by extension, the Emergency Departments (EDs). This is because Omicron is a less dangerous variant, and our population has become more resilient due to vaccinations and safe recovery from infections.

3     Hence, over the past year, I have reported to this House on several occasions that although we did not let the virus overwhelm our healthcare system, our hospitals, and especially the EDs, have been very busy.

The Burden of Endemicity

4     Why are the hospitals still experiencing heavy workload, given that life has gone back to pre-COVID-19 normal?

5     The simple and fundamental reason is that the pandemic is not over. It may feel like it is over for most of us, but it certainly is not over for our hospitals and healthcare workers. We are learning to live with the virus as an endemic disease. As I have explained to the House before, endemicity does not mean that the virus disappears from our lives. On the contrary, it means it is a permanent feature of our lives, circulating amongst us, and we have to take personal precautions and implement public health measures in order to manage and live with it.

6     What are these public health measures? Essentially, there are three. First, Safe Management Measures (SMMs) to restrict social interactions and therefore reduce viral transmission. Second, transmission still happens and therefore we do vaccinations so that infections do not translate into many cases of severe illness and death.

7     When the first two cannot be prevented, the third lever – which is our healthcare system – will then have to catch the problem and manage it, by treating and caring for infected patients who become severely ill.

8     Now let us take stock of these three measures: For SMMs, we have removed almost all restrictions, so that life goes back to pre-COVID-19 normal. This is what all Singaporeans wish for and the whole point of treating COVID-19 as an endemic disease. Therefore, the Multi-Ministry Taskforce (MTF) has been very reluctant to reimpose SMMs unless absolutely necessary.

9     Second, vaccinations. We have already covered the great majority – over 90% – of our population. The vaccination exercise is ongoing but this is largely to extend our coverage at the margins, namely now infants and very young children, and to keep vaccinations up to date for the others. We are just maintaining our immunity and resilience, now no longer able to achieve the kind of quantum improvement in resilience that we could achieve when we first started our national vaccination programme.

10     That means the burden of endemicity will fall disproportionately on the last public health measure – which is our healthcare system. That is why our wards and EDs have been very busy over the past year. The media highlighted it only recently, but our hospitals have been experiencing it for the whole year.

11     I hope that as we enjoy our hard-fought freedom from COVID-19, we remember the toil and sacrifice of our healthcare workers – doctors, nurses, social care workers etc. – in order to secure freedom and the state of endemicity for the rest of society. COVID-19 may feel like it is over for many of us, it is not over for them.

12     Therefore, in the hospitals and EDs, service levels may drop and waiting times become longer. Out of frustration, there will be public complaints and we understand, but I sincerely hope that our hospitals and healthcare workers will continue to receive the appreciation, understanding and support from all Singaporeans.

A Fuller Picture

13     Sir, let me now describe what exactly the situation is at the EDs today.

14     First, I want to assure the House, for critically ill patients, they are attended to almost immediately at the EDs, due to the way we triage patients and allocate resources. So priority always goes to them.

15     For non-life-threatening but emergency cases, the median waiting times for consultation across all our EDs averaged about 20 minutes from January to September this year. It is not a very long wait, and it is important for this group of patients to be attended to quickly, so that they are evaluated and then discharged promptly.

16     For emergency cases that require hospital admission – that is where the bottleneck is – the median waiting times for wards is about seven hours, from January to September. This is a few hours longer than 2019. But seven hours is the median, and there is variation.

17     So when we have an infection wave, like recently, waiting times can spike up sharply, to the reported 50 hours for certain hospitals that are busier.

18     Despite the heavy workload, our hospitals will not compromise the safety of patients. As mentioned earlier, life-threatening cases will be attended to immediately. If surgery is required, it will be carried out promptly and beds will be there for these patients.

19     For non-life-threatening patients waiting for admission, medical teams will continue to monitor them and institute appropriate investigations and treatments.

20     For bedridden patients who are at higher risk of developing pressure injuries, hospitals will implement preventive nursing interventions. This includes the use of thicker mattresses or air mattresses, turning of the patient periodically, and changing of diapers and drawsheets for bedridden patients.

Diagnosing the Causes of the Problem

21     Sir, I will now address the most pertinent question, which is what can we do about crowded EDs and alleviate the problem?

22     The current situation, make no mistake, is not sustainable, and we need to resolve it. But it has not been easy to solve the problem as we are still in the middle of a pandemic. Each time after a wave subsided and we started dealing with the problem, another wave came, and attention and resources were diverted to fight the fire again.

23     With the XBB wave subsiding earlier than expected, we hope this time round, we have the time and space to deal with the problem properly and decisively. To do so, we need to diagnose where exactly is the operational bottleneck.

24     The issue actually is not the EDs. It really is about matching the demand and supply of hospital beds. The crowdedness and long waiting times for patients at the EDs in some hospitals, especially during a wave, is a manifestation of the problem of the mismatch of demand and supply of hospital beds.

25     Let us look at the demand for hospital beds. If we look at average monthly ED attendances, which translates into demand for hospital beds – from 2019, before COVID-19 started, to 2022, there is a reduction from 75,000 per month, to 63,000 patients per month. This translates to a daily attendance of about 2,500 patients a day in 2019, to 2,100 patients a day in 2022. This is a 16% decrease.

26     Hence, it would appear that all our measures to educate the public not to go to EDs unless absolutely necessary, the GPFirst initiative, the setting up of Urgent Care Centres in the heartland as an alternative, have all worked. Or it could be a simple reason that during a pandemic, people actually do not like to go to the EDs.

27     However, while the overall numbers dropped, if you look at all ED attendances, the proportion of patients with the highest acuity, or the most serious conditions, need the most attention and probably need hospital beds, had increased from 8% in 2019 to 11% in 2022. In absolute numbers, this is an increase of a few hundred patients per month. It is not huge, but it does add to the operational burden of hospitals.

28     More importantly, I think, is this point that we are again looking at averages; while the average number has come down during the pandemic, that number is a lot more volatile. During an infection wave, many more infected people and recovered patients go to the EDs.

29     For example, at the peak of this mid-year Omicron Wave and recent XBB wave, COVID-19 infected patients added another 600 ED visits every day. This is 30% more workload at the ED, which is very significant.

30     I should mention a separate problem that we now encounter at the KK Women’s and Children’s Hospital, the ED has been experiencing very high visits every day – at levels that they used to experience only during Chinese New Year when all other clinics are closed.

31     This is a separate problem, due to what we call an ‘immunity debt’ in children. It means that for the past two years, SMMs including mask wearing has shielded children from many forms of viral infection, and not just COVID-19. Now that life is back to normal, viral infections are making a strong come back and demanding payback, with interest.

32     Now, let us look at the supply side of the hospital beds. There are a few factors constraining the supply, and slowing down the process of warding ED patients.

33     First, due to our ageing population, there is a secular trend of rising number of patients with long stays, which reduces the turnover of hospital beds. To illustrate, the percentage of patients who stay longer than 21 days has doubled from 1.6% of all hospitalised patients in 2019, to 3.8% in 2022.

34     Second, the pandemic caused construction disruptions which delayed the opening of healthcare facilities, namely the Woodlands Health Campus and the Integrated Care Hub at Tan Tock Seng Hospital. If these facilities had opened as originally planned in 2022 without the COVID-related delays, they would have added at least a few hundred beds to our system, and would have alleviated the problem.

35     Similarly, construction delays due to the pandemic have also postponed the opening of several nursing homes and community day care facilities, and that also constrained the ability of hospitals to discharge less acute patients and free up hospital beds.

36     Third is supply constraint. As part of our emergency planning, hospitals are required now to set aside or ringfence beds for the care of COVID-19 patients. Members of the House may recall at the height of the pandemic when we had to impose SMMs to preserve healthcare capacity, many Parliament questions were filed, asking MOH if we had planned for adequate healthcare capacity in such emergency scenarios.

37     Ringfencing hospital beds for COVID-19 patients is part of that planning effort. However, we inject flexibility into the plan, raising or lowering the number of ringfenced beds according to the pandemic situation.

38     For example, at the peak of the recent XBB wave, we set aside 800 beds for COVID-19 patients. About 80% were occupied at the peak of the wave, which meant we still had 160 beds unoccupied for contingency purposes. Although this is not a big number, it nevertheless constrained hospital operations and impeded the clearing of patients waiting at the EDs.

39     Whether due to demand or supply factors, we need to recognise that we run a very high throughput hospital system. In such a system, even a very small mismatch of demand and supply of a couple hundred beds will cause waiting times to spike up very significantly.

40     It is not very different from an expressway with very heavy traffic flow. All it needs is one branch falling on one or half a lane, and you have a massive traffic jam. We have a similar situation in a very high throughput hospital system.

Remedies to Crowded EDs

41     So, how do we resolve the current problem?

42     The hospital clusters, working with MOH, have issued a statement recently outlining all the measures they are taking. They continue to be relevant and we will continue to pursue them.

43     To briefly recap, these measures include reducing ED demand through primary care and alternative pre-hospital care options, educating the public to use EDs only when absolutely necessary, diverting them to nearby primary care clinics and coordinating with SCDF to divert less serious cases away to less crowded EDs.

44     We are also actively transferring patients in acute hospitals to step down or home care whenever possible. We are partnering private hospitals such as Raffles Hospital to accept patients sent by SCDF ambulances for emergency medical treatment and we offer subsidised rates.

45     New nursing homes are coming on stream and they are very helpful during the XBB wave.

46     From the end of next year, the Woodlands Health Campus and Tan Tock Seng Hospital Integrated Care Hub should start to open progressively. Over the next five years, we target to add about 1,900 more public hospital beds, including the above two projects and also the expanded Singapore General Hospital Medical Campus.

47     Today, let me focus on two important structural adjustments that we will make, which will hopefully help alleviate the crowdedness at the EDs in the short term.

48     One, we will activate more Transitional Care Facilities (TCFs). Three TCFs are already in operation, with a total of about 400 beds. These are operated by private providers at wards in Sengkang Community Hospital, Changi Expo Hall 10 and Crawfurd Hospital along Farrer Road, which opened just last week.

49     The TCFs serve a special purpose: they admit medically stable patients from public hospitals while they wait for their transfers to intermediate 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.

50     But TCFs are not just about providing beds space that is operated by private hospitals. There has to be a very firm handshake between the TCF operator and a public hospital.

51     With that firm handshake, the privately-operated TCFs will gain confidence in admitting patients transferred by a public hospital, because they will feel assured that should they need any clinical help in unforeseen circumstances and complications, the public hospital will still step in. Without this understanding, TCFs will naturally be very conservative in admitting patients and there will be very little movement in stable patients.

52     The Sengkang Community Hospital TCF run by Thomson Medical Centre is a very good example. They have a very strong partnership now with Sengkang General Hospital.

53     We will replicate this, to pair up Changi General Hospital with EXPO Hall 10 run by Raffles Medical Group, and Tan Tock Seng Hospital with Crawfurd Hospital. We are actively working on new TCFs in the north and in the west, to partner Khoo Teck Puat Hospital and Ng Teng Fong General Hospital respectively.

54     The second structural shift is that our approach to live with COVID-19 needs to be extended to hospital operations as well. It is time for us adopt a more flexible and balanced approach to hospital bed assignments.

55     We should move away from ringfencing beds just for COVID-19 patients. We had done so in earlier stages of the pandemic, when hospitalised COVID-19 patients faced a high chance of developing very severe illness, and numbers could spike very high during an infection wave. Hence, reserving beds, and actually we reserved wards, was an appropriate thing to do.

56     However, we are now at the stage when most residents have been vaccinated and boosted or recovered safely from COVID-19, and have good levels of hybrid immunity against severe illnesses. We should therefore allow hospitals to triage or assess their patients based on clinical severity and priority for treatment, and not manage COVID-19 patients to a different standard.

57     This flexibility is important to our hospitals, to help them optimise the use of beds. In a crunch situation, just like an expressway with very high throughput, it makes all the difference.

58     With this change, hospitals will no longer set aside whole wards to cohort COVID-19 positive patients as a standard pandemic practice. They will continue their current practice of using isolation beds for patients with infectious diseases, including COVID-19, if there is a risk of infection spread.

59     This is not a sudden change, but a transition process that has started and has been ongoing. Hospitals will continue to exercise various precautionary measures on infection control, to protect the vulnerable and prevent spreading of infectious diseases in hospitals. They have done so for many years, for influenza and all kinds of infectious diseases, and they will apply the same measures now for COVID-19, but without setting aside entire wards which would stall their operations.

We Can All Do Our Part

60     Beyond these two structural measures, every one of us can do our part.

61     While ED attendances have fallen compared to 2019, non-urgent cases still make up 40% of all ED attendances. We can use EDs more judiciously. Use alternatives, such as a GP clinic or call our family doctors.

62     We should exercise social responsibility such as staying at home, and self-testing when not feeling well. Most importantly, we need to continue to keep our vaccinations up to date and prevent ourselves from falling severely ill if we are infected by COVID-19. Today, a senior without minimum vaccination protection is still about three times more likely to end up in a hospital and needing to be warded than one with minimum vaccination protection. By taking another jab to keep vaccination up to date, you may well be freeing up an additional hospital bed.
 

63     If we can do our part, we will help healthcare workers earn back their normalcy of life, as they have sacrificed and worked hard to earn our freedom and normalcy of life.