Emergency department crowding in Singapore: Insights from a systems thinking approach

Objectives: Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care. Methods: The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied. Results: The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created. Conclusion: Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options.

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The International Federation for Emergency Medicine report on emergency department crowding and access block: a brief summary

International Journal of Emergency Medicine ◽

10.1186/s12245-020-00312-x ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

A. P. Javidan ◽

◽

K. Hansen ◽

I. Higginson ◽

P. Jones ◽

...

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Task Force ◽

Video Conferencing ◽

International Federation ◽

Emergency Physicians ◽

Emergency Department Crowding ◽

Comprehensive Guidance ◽

The World ◽

Ed Crowding

Abstract Objective To develop comprehensive guidance that captures international impacts, causes, and solutions related to emergency department crowding and access block Methods Emergency physicians representing 15 countries from all IFEM regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020. Results A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force. Conclusions The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

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Common geriatric emergencies

Oxford Textbook of Geriatric Medicine ◽

10.1093/med/9780198701590.003.0140 ◽

2017 ◽

pp. 1081-1086

Author(s):

Simon Conroy ◽

Rosa McNamara

Keyword(s):

Older Adults ◽

Emergency Department ◽

Emergency Medicine ◽

General Population ◽

Older People ◽

Discharge Planning ◽

Population Ageing ◽

Younger Adults ◽

Current Trends ◽

Geriatric Emergency Medicine

Older adults make up an increasing share of emergency department (ED) users, as the proportion of those aged 65 years and older increases in the general population. Older adults often have physical, physiological, psychological, and social considerations which demand a different approach to evaluation, management, and discharge planning compared to most younger adults using the ED. Older people are also more likely to have accumulated morbidity throughout their life course. Thus, a focus on geriatric emergency medicine has become an increasingly important as clinicians adapt to meet the challenges of population ageing. Here we outline the current trends in ED usage by older adults and give an overview of how care of older people is structured in emergency medicine.

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The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary

Emergency Medicine Journal ◽

10.1136/emermed-2020-210716 ◽

2021 ◽

Vol 38 (3) ◽

pp. 245-246

Author(s):

Arshia P Javidan ◽

Kim Hansen ◽

Ian Higginson ◽

Peter Jones ◽

Eddy Lang

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Task Force ◽

Video Conferencing ◽

International Federation ◽

Emergency Physicians ◽

Emergency Department Crowding ◽

Comprehensive Guidance ◽

The World ◽

Ed Crowding

ObjectiveTo develop comprehensive guidance that captures international impacts, causes and solutions related to emergency department (ED) crowding and access block.MethodsEmergency physicians representing 15 countries from all International Federation of Emergency Medicine (IFEM) regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020.ResultsA total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force.ConclusionsThe IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

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Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine

European Geriatric Medicine ◽

10.1007/s41999-021-00578-1 ◽

2021 ◽

Author(s):

J. A. Lucke ◽

S. P. Mooijaart ◽

P. Heeren ◽

K. Singler ◽

R. McNamara ◽

...

Keyword(s):

Older Adults ◽

Emergency Department ◽

Emergency Medicine ◽

Task Force ◽

Clinical Recommendations ◽

European Task ◽

Geriatric Emergency Medicine

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Canines in the emergency department: a novel approach to stress reduction in emergency medicine providers

Proceedings of IMPRS ◽

10.18060/22678 ◽

2018 ◽

Vol 1 (1) ◽

Author(s):

Jacob C. Davis ◽

Kimberly J. Van Ryzin, MD ◽

Courtney T. Linville ◽

Kate L. Pettit, MS ◽

Jeffrey A. Kline, MD

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Art Therapy ◽

Stress Reduction ◽

Emergency Care ◽

Current Data ◽

Care Providers ◽

Therapy Dog ◽

Validated Questionnaire ◽

Novel Approach

Background and Hypothesis: Cognitive stress during shiftwork contributes to burnout in emergency care. We hypothesize that if emergency care providers (physicians and nurses) were to interact with a therapy dog, their stress levels will decrease. Experimental Design or Project Methods: Consenting emergency medicine physicians and nurses provided three self-reported assessments of stress as well as saliva samples near the beginning of their shift. During peak hours in the emergency department at Eskenazi Hospital participants are randomized to interact with either a therapy dog or perform a mindfulness exercise via art therapy for five minutes. Self-perceived stress and saliva samples are obtained 30 minutes later and again near the end of shift. To assess potential change in participant behavior, patients of providers in either group receive a validated questionnaire assessing perceived empathy of the provider. Salivary cortisol will be measured at the end of the study by a vendor (Salimetrics). The sample size of 40 per group is predicated on a 25% decrease in self-reported stress in the dog group on the emergency care worker stress scale (ECWSS). Results: From June 1 to July 10, 24 participants have been randomized (12 in each group). Seven participants (58%) exposed to dogs had a mean decrease in the ECWSS of -5 (+/-1.8) compared with four participants (33%) who had a mean decrease of -2 (+/-0.8) after art therapy. The mean overall change in ECWSS after dog was -2 (+/-1.5) vs. +3 (+/-1.5) after art therapy. Current data suggest a greater decrease of self-reported stress after interaction with a therapy dog, compared to art therapy. Conclusion and Potential Impact: Interim analysis suggests that exposure to a therapy dog decreases stress in a subset of emergency care workers. This work will help determine if human-animal interaction can modulate stress biology imposed by providing emergency medical care.

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Modeling Emergency Department crowding: Restoring the balance between demand for and supply of emergency medicine

PLoS ONE ◽

10.1371/journal.pone.0244097 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0244097

Author(s):

John Pastor Ansah ◽

Salman Ahmad ◽

Lin Hui Lee ◽

Yuzeng Shen ◽

Marcus Eng Hock Ong ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

Emergency Medicine ◽

Primary Care Clinic ◽

Public Hospitals ◽

Care Clinic ◽

Care Services ◽

Primary Care Services ◽

Number Of Patients ◽

Ed Crowding

Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage―a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor’s consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients’ average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.

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