Saturday, 11 January 2014

Managing the bed crunch in hospitals

New procedures, facilities added over the years
By Salma Khalik, The Straits Times, 10 Jan 2014

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.

Each time they occur, new procedures, facilities or stop-gap measures are introduced to meet the growing demand.

Some of the more extreme measures taken in the past decade have seen rooftop gardens converted into wards and beds placed in corridors.

By the mid-2000s, hospitals had made a major change to tackle the problem by introducing same-day admission for surgery. This saved public hospitals 17,000 bed nights a year, as previously patients had to check in the night before they were due to go under the knife.

But in 2006, the flu season sparked a massive influx of patients suffering from pneumonia that filled all the beds at Singapore General Hospital (SGH), Tan Tock Seng Hospital (TTSH) and Changi General Hospital (CGH), with some complaining of a 24-hour wait to get one.

Overcrowding at TTSH resulted in the hospital periodically closing its doors to non-critical ambulance cases, which were diverted to other hospitals.

The Ministry of Health (MOH) said the bed crunch was seasonal. Nevertheless, it planned to add 80 more beds to public hospitals.

There was no let-up in 2007 as Singapore's rising population pushed bed occupancy at some public hospitals beyond 90 per cent.

CGH faced an occupancy of 98 per cent on some days that year and had to take over a ward of 33 beds from St Andrew's Community Hospital next door.

MPs suggested that patients were unwilling to move to a community hospital or nursing home because of heavy government subsidy in general hospitals.

Then Health Minister Khaw Boon Wan assured Parliament that MOH would add 60 to 100 beds a year until the population stabilised. About 150 more were added in 2007.

Hospitals also introduced more day surgeries so patients could spend less time in the wards.

Still there was no let up the following year. In 2008, SGH and TTSH experienced a more than 10 per cent surge in patients at its emergency department, while occupancy rates of over 90 per cent were common across the country.

One patient was even told there were more than 100 people in queue for beds ahead of him

In 2010, TTSH gave a new meaning to the term C-class beds - installing temporary beds in its corridors. It also transferred 80 stable patients to Ren Ci Community Hospital.

SGH, with occupancy of 87 per cent, cut the number of non-emergency surgery to cope with demand. It also discharged patients earlier in the day to free up beds, as did TTSH.

Meanwhile, National University Hospital (NUH) dealt with the problem by offering patients outpatient intravenous antibiotic treatment instead of warding them.

Those with suspected heart problems were sent for immediate tests and warded only if they were confirmed.

It also leased a ward of 30 beds from the private Westpoint Hospital, sending its doctors and nurses there to care for patients.

With CGH juggling with occupancy peaking at 99 per cent, there was a sigh of relief when Khoo Teck Puat Hospital opened its doors early. It filled up almost immediately but eased the crunch on other hospitals.

Also in 2010, SGH leased two wards from Alexandra Hospital that year, manning them with its own staff.

Several hospitals looked to get to the root of the problem and started schemes to help "frequent fliers" - patients who are hospitalised several times a year - stay healthy. They made checks on their health or even sent staff to visit them at home, drastically reducing their need for hospitalisation.

In 2011, one year after the opening of the 550-bed Khoo Teck Puat Hospital (KTPH), public hospitals were faced with more bed shortages. Worst hit were TTSH, CGH and KTPH.

CGH added temporary beds in its therapy areas and sent patients straight for surgery while a bed was being located.

All struggling hospitals sent stable patients without a bed to Alexandra Hospital by ambulance.

TTSH borrowed close to 300 beds from Ren Ci Community Hospital, Ang Mo Kio-Thye Hua Kwan Hospital and the Communicable Diseases Centre. It even turned its decontamination area into a holding place for patients in the emergency department - though this attracted complaints about its cement floor and stuffiness.

The crunch was blamed on the growing number of elderly Singaporeans, who are more frequently sick and need to spend longer in hospital.

By 2012, CGH was sending patients recovering from hip fractures to Peacehaven Nursing Home, where they could continue to be treated by its medical staff.

In a push for greater capacity, it leased a ward of 30 beds from the private Parkway East Hospital and also converted office and shop space - as well as an unused road - into its admission transit area. This gave it space for 25 beds for emergency patients awaiting a ward bed - on top of its observation and resuscitation areas.

KTPH, meanwhile, moved skywards, converting one of its rooftop gardens into a 32-bed ward.

As dengue fever took hold last year, CGH entered into yet another agreement with the private Gleneagles Hospital for it to take in up to a dozen patients with the mosquito-borne virus.

It looks like CGH's problems are continuing unabated after hitting the headlines again a few days ago, having set up a tent to hold up to 15 patients at its emergency department who were waiting for ward beds.

And there is a sense of deja vu as TTSH places beds in its corridors again, and some hospitals send stable patients to Alexandra Hospital.

Bed crunch: Better care network needed
By Lim Yan Liang, The Sunday Times, 12 Jan 2014

The solution to the ongoing hospital bed crunch cannot just lie in adding new beds. Instead, a network of patient care outside of a hospital is necessary, said the head of the upcoming Ng Teng Fong General Hospital yesterday.

"The centre of gravity (in patient care) cannot be in an acute hospital setting," said Mr Foo Hee Jug, who is now chief executive at Jurong Health Services.

"We must do and plan activities right now to get patients comfortable with community care."

Pointing to programmes like Tan Tock Seng Hospital's "virtual hospital" where health managers are on hand 24/7 to advise elderly patients by phone or through home visits, Mr Foo said that expanding transitional and community care by partnering doctors and primary care providers can help alleviate shortages.

Jurong Health Services is moving in this direction by working with polyclinics to set up family medicine clinics and collaborating with private general practitioners so that residents can seek care for different ailments outside of a hospital setting.

"Patients who would otherwise have stayed in an acute hospital can (then) actually go home, knowing that at the right time, we will be able to... bring our doctors and nurses in," he said.

Mr Foo was speaking at a community event at JEM in Jurong yesterday, where more than 2,000 people signed a cement slab that will be hoisted to the top of Ng Teng Fong General Hospital tomorrow, to mark the completion of the inpatient tower.

Mr Foo said that the upcoming hospital is on track to open its first phase by the end of December.

About 500 beds will become available there at the end of this year, with another 200 available in its community hospital section.

The Jurong Community Hospital, which will be adjoined to the Ng Teng Fong General Hospital, is also on track to open in the third quarter of 2015, said Mr Foo.

When the hospital opens, it will add another 400 beds.

The two hospitals will serve the 900,000 residents in the western part of Singapore, and help alleviate the bed crunch faced by the National University Hospital and Singapore General Hospital.

Things to note
By Salma Khalik, The Straits Times, 10 Jan 2014
Given the current bed crunch, should I go to a hospital if I'm very sick?
If your illness can be treated by a general practitioner (GP), it might be better to see a GP. You will get treated faster.

However, if you suspect you might have a heart attack, stroke or other serious medical problem, call for an ambulance. Even if a bed is not available, doctors will attend to you immediately and begin treatment.
Can I tell the ambulance to go to Singapore General Hospital or Alexandra Hospital which have beds?
No, emergency ambulances are obliged to take you to the nearest hospital.
Should I take the hospital's offer to move me to another hospital?
Yes. Your condition would be considered stable. You will get a bed much faster and it beats waiting in a transit area.
If the hospital wants to discharge me, but I still feel sick, what should I do?
Tell the doctor or nurse your concerns. Ask them what you should do if your illness recurs. Ask for a number to call should that happen. If you are still afraid to leave, ask that you not be discharged. But bear in mind that there are many very sick people who need beds urgently.

Do not delay the discharge simply because you prefer spending another day in hospital or there is no one to pick you up.
If I have waited a long time in the Emergency Department, can I just leave before seeing a doctor? Will I be charged?
You may leave at any time but do let the staff know. You will not be charged. If you are at Changi General Hospital, they have a list of nearby general practitioners who can treat non-critical illnesses.

Tackle bed crunch now
By Salma Khalik, The Straits Times, 14 Jan 2014

SINGAPORE is experiencing its worst bed crunch ever.

Asked what the Ministry of Health (MOH) is doing about it, Health Minister Gan Kim Yong told The Straits Times that he is "cognisant" of the problem, and the Government will add 3,700 beds by 2020.

He added: "In the short term, Ng Teng Fong General Hospital is scheduled to open in 2014, and community hospitals in Yishun and Jurong will be ready by 2015."

There is a Chinese saying that distant water cannot put out a nearby fire.

Yes, there should be relief for the bed crunch by the end of this year. But what is going to happen to patients between January and December?

National University of Singapore sociologist Paulin Straughan was quoted recently as saying that the current situation has reached "crisis level".

That may or may not be overstating it. But the fact is that several public hospitals are resorting to extreme measures to cope with the deluge of patients. Patients sick enough to need hospitalisation are being put up in beds at temporary tents or along hospital corridors .

What is needed are immediate, even if temporary, solutions.

As it is, Changi General Hospital, which has put up patients in a tented shelter, is not the only hospital facing such a severe bed crunch.

Associate Professor Straughan said her husband had to wait 12 hours for a bed at the National University Hospital last week. He had to sit in a chair with a drip in his arm for several of those hours.

Over at Singapore's newest public hospital, Khoo Teck Puat Hospital (KTPH) in Yishun, the situation was just as bad.

Its emergency department has 18 cubicles for patients waiting for a bed. Each cubicle is meant to house one bed. But early last week, the hospital had to squeeze two more beds into each cubicle.

Yet even that was not enough to cope with the non-stop flood of patients needing hospital care. Another 20 to 30 patients ended up lying head-to-toe on trolley beds along three corridors near the emergency department.

Tan Tock Seng Hospital was equally stretched. But it was able to cope by having up to 49 temporary beds along its ward corridors, and taking over and opening two 13-bed wards from the nearby Communicable Diseases Centre last week.

All these hospitals are experiencing average weekly occupancies of well over 90 per cent. The bed count is taken at midnight, and some of these "spare" beds are occupied within hours as more patients pour in.

Hospital heads are saying that on some days, their real occupancy exceeds 100 per cent.

All this means that even as Singapore looks forward to the long Chinese New Year weekend at the end of this month, the hospitals are dreading it, as the post Chinese New Year period is a traditional peak period.

How much above 100 per cent can these hospitals go in terms of occupancy, before there is a real negative effect on patient care?

Hospitals are already discharging "less sick" patients - who may not have fully recovered - to make way for those needing a bed more urgently. They have to do this. They have no choice, whether patients like it or not.

The hospitals cannot be faulted for the current situation. They have done their best over the years to cope with a bad situation as best they can.

They have tried to provide care in patients' homes to keep them healthy and out of hospital.

They have introduced same- day surgery. Instead of requiring patients to spend a night at the hospital before surgery, patients go from home straight to the operating theatre. This has saved more than 17,000 bed days each year at the six public hospitals.

More operations are now done as day surgery, where patients are discharged the same day after their operation. Today, day surgery makes up 70 per cent of operations, up from half 10 years ago. This has cut demand for hospital beds - but not fast enough.

With a population that is both growing and ageing, the increased call on hospital services is a given. Proper planning and timely intervention could have prevented the severe bed crunch hospitals are struggling with.

In fact, bed shortage is a chronic problem in Singapore hospitals that flares up into an acute crunch every now and then.

Many people are asking how the bed crunch got to this serious state. That question needs to be answered - but the priority right now must be to find solutions to the problem.

Mount Elizabeth Novena, which has not fully opened all its wards, has offered to rent out up to two of its 30-bed wards for use as public hospital wards. It has also offered to help provide manpower to service the wards if needed. For a start, MOH should take up this offer. But even those 60 beds might not be enough.

MOH could also do what it did during Sars in 2003, when it took over the six-storey building meant for Ren Ci Community Hospital and turned it into a second communicable diseases centre. It could, for example, take over the premises of a new nursing home and use them to house patients who are stable and recovering, but still not well enough to go home.

Or MOH can put up temporary buildings to house patients. After all, the country is able to put up temporary buildings at top speed every year for an event like the Formula One night race and take them down quickly. A temporary hospital may be a more complex operation, but should not be beyond Singapore's capability.

It can also step up the home- care services that have been talked about for some time, but appear slow in building up. This frees hospital beds by having stable patients looked after by professionals in their homes.

To expand home care, the government has to look into providing home-care subsidies that are as attractive as that for hospitalisation, which is up to 85 per cent subsidised.

Efforts to boost manpower supply must also be stepped up.

MOH also needs to recognise that given the current state of affairs, urgent action is called for.

It should also not regard the 700-bed Ng Teng Fong Hospital in Jurong as a panacea. The relief public hospitals got with the opening of the 550-bed KTPH in 2010 lasted barely a year.

MOH should seriously consider bringing forward the opening of the Sengkang hospital from 2018.

It is better to have a slight oversupply than the shortage now afflicting the public health-care system.

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