Bed crunch at Singapore hospitals: Some patients are stuck in emergency departments
Emergency department (ED) doctors say there are days when the situation is so bad that an ambulance arriving is unable to discharge the patient for lack of space. Instead, the medical team has to assess the patients while they are on the ambulance trolley.
Those who are in critical condition are treated immediately. Others might have to wait 15-30 minutes for space to be found so that they can be offloaded and the ambulance can leave.
This also holds up the ambulance, which might be urgently needed by another critically-ill patient.
The Singapore Civil Defence Force, which runs the emergency ambulance service, said there has been a 32 per cent increase in calls in the first half of 2022 over the previous year, of which 93 per cent were real emergencies.
The Ministry of Health (MOH) says hospitals will mitigate the situation during peak congestion periods through measures such as adding more beds to wards and creating holding spaces in EDs. At least one hospital has converted a consultation room to hold such patients in recliner chairs when it is short of beds.
The Straits Times spoke to several ED doctors and nurses who asked that they and their hospitals not be identified. They say the problem has been around for years, but has become worse this year, partly on account of the surge in Covid-19 cases.
They say they are no longer surprised that a patient they had admitted was still around when they return to hospital for their next shift. On some occasions, the patient might still be in the ED for up to four days after being admitted.
“Patients remaining in ED days on end is now the norm,” said emergency medicine specialist.
Another said: “I’m no longer as surprised as before, but yes still surprised when I see the same patient and next of kin a few days later in the ED.”
Mr Anthony Pragasam, 91, was one such patient. He was taken to a public hospital ED at 3 pm on Sept 20, and was officially warded at 8pm. But he remained in the ED for two days before he was sent to a ward at 6pm on Sept 22.
Because he was in the ED, no visitors were allowed. Said his son: “I am quite certain he did not get a shower but there’s just no way to know, as we weren’t allowed inside.
“There needs to be a rethink about holding patients in the ED without easy access to family members, especially elderly ones like my dad who have dementia, are unable to communicate clearly and cannot ask for what they need. And to keep family members away from the patient for two days without any of us to see how he is doing, I think that cannot be allowed to happen.”
According to MOH’s published data, for the last two weeks of September, the median wait time for a bed at Ng Teng Fong General Hospital on six of the 14 days was 22 hours, 22.3 hours, 22.7 hours 23.1 hours and 23.7 hours and 24.2 hours. Weekends were generally less crowded and the shortest wait time was 7.6 hours on a Saturday.
In August, the longest median wait time for this hospital was 25.4 hours.
No data for this month is available yet, but with the current Covid-19 wave, numbers are likely to remain high.
EDs are not meant to keep patients for long – only for urgent treatment after which they are either discharged, or sent to a ward. Hence, it does not have shower facilities, or even sufficient patient toilets.
At Changi General Hospital, some less sick or frail patients sometimes have to wait in recliner chairs when there are no more beds available. Because of lack of space, beds are sometimes so close to each other that just by stretching out a hand, they can touch the patient in the next bed.
A nurse said that in order to administer drugs or to take the blood pressure, she needs to pull the bed out as there is not enough space between beds for her to squeeze into.
She added that it is especially difficult when managing bed-bound patients who require regular nursing care, such as having to be turned frequently in the trolley, being tube-fed and getting their diapers changed.
Both doctors and nurses admit to being frustrated.
Said a doctor: “There is no privacy. Patients cannot rest properly as the ED is a very busy, noisy place. It is challenging to find patients and to get to the patients to examine them or speak to them with the appropriate dignity and privacy.”
Another doctor said: “Inpatient doctors can’t find their patients as they are all over the place. Patients are stacked like sardines and can’t sleep or eat or go to the bathroom without other people in attendance.”
She said it was quite common now to have 70-80 patients in the ED who have been admitted on paper, but who have not been moved out to a ward.
Her colleague added that having surges in ED is something they expect and can cope with – but not when the surge “is no longer once in a while, but a constant problem”.
They say the problem preceded the Covid-19 pandemic, but has been exacerbated by it as the bed crunch has become more severe.
They are frustrated because they have been flagging the problem to their hospital heads over the years, but the situation has not improved. One said it should not be seen as an ED problem, but as a whole of hospital problem.
Aside from facing surges caused by patients with Covid-19, public hospitals have lost many of their junior doctors who left because they could earn a lot more in a few months doing pandemic related work than they would in a year at the hospital.
Many foreign nurses have also left for their home countries, after being stuck here for more than two years due to travel restrictions.
Ms Rovy Martinez is one such nurse, who left recently after working 10 years here in public hospital emergency departments. She said she used to enjoy her work in ED, but not in the past year.
“Bad days occur everyday this year,” she said. “Safe practice should have one nurse taking care of three patients in ED. But we now have one nurse taking care of 4-6 stable admitted patients.”
But with resignations and patients unable to be moved out of ED for lack of ward beds, she recalled: “Sometimes we even had two nurses managing more than 50 patients.”
One reason she, and many of her colleagues, left was because they felt they were no longer able to give patients the quality of care needed.
She said: “Nurses are overwhelmed and won’t be able to manage all the problems. Most of the times, nurses won’t go for any break, even toilet privileges were impossible. They will even stay back longer because there’s no receiving staff to take over for the next shift.”
This problem is not unique to Singapore. Hospitals around the world are facing similar stresses on their system.
Quebec’s Health Minister Christian Dubé said in February that in 2021 “1,400 patients died on stretchers in Emergency Rooms while waiting to be transferred to a ward.”
Doctors there pointed out that it doesn’t mean patients had died because they could not be transferred to a ward where they could get better care. They may have died anyway, but it is nevertheless, a major red flag.
An emergency medicine specialist said patients still receive good care, but having too many patients can affect the quality of care given.
She said: “ED nurses are assigned to take care of these patients as long as they are physically in the ED. This means fewer ED nurses for other areas of acute care in the ED, which in turn impact our work as doctors in those acute care areas.”
Another doctor whose hospital has converted a consultation room to hold ED patients on recliner chairs, said: “I just had a shift where every nook and corner was stuffed with chairs and trolleys with patients.”
One hospital which appears to be managing patients in its ED fairly well is Tan Tock Seng Hospital (TTSH) – in spite of having one of the largest ED intakes and one of the highest bed occupancy rates here.
Over the last fortnight in September, it had median wait times of 5-12.4 hours in spite of having the highest ED intake of 5,290 patients and its ward occupancy rate hit a high of 101.8 per cent.
Some years ago, it put in a rule that patients must be moved out of the ED within a certain period, or if the number of patients there crosses a pre-determined number. Patients will be upgraded to higher class wards, and if necessary, all wards will need to take in extra patients.
And when push comes to shove, it will cancel non-urgent surgeries scheduled for the next day – a move that is extremely unpopular with both its doctors and patients – but deemed necessary to cope with the surge of patients