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

Abstract

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.

Mapping the Dynamic Complexity of Chronic Disease Care in Singapore: Using Group Model Building in Knowledge Elicitation

“…A negative relationship indicates that an increase in the cause variable will result in a decrease in the effect variable, all things being equal. A set of parallel lines over an arrow signifies a significant time lag between cause and effect variables (Schoenenberger et al ., ). This model builds upon prior quantitative system dynamics models for chronic disease care.…”

“…As a result, the acute hospitals and specialist services that have been the focus of a health system designed for a younger population needing episodic and disease‐oriented care have been showing signs of systemic stress (Ministry of Health, ). This is evident in the high bed occupancy rates in acute hospitals (Lam, , Ministry of Health, ), overburdened SOCs (Ministry of Health, ), increasing ED utilization (Anantharaman, , Schoenenberger et al ., ), long waiting times for admission to acute hospital wards (Ministry of Health, ) and workforce shortages (Kang and Leong, , Ministry of Health, ). Hospital admissions due to diabetes, for instance, are much higher in Singapore (432 per 100 000 population) than in countries such as the United Kingdom (64) or the United States (149) (OECD, ).…”

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

“…(1) Crowding is an undesirable phenomenon, as it can compromise the quality of care to ED patients, which may in turn have an adverse impact on their health outcomes. (2)(3)(4)(5) Studies have shown that ED crowding is detrimental to the morale, (6) productivity (2,7) and training (8) of ED staff. Over the years, the problem has grown and is affecting the healthcare systems in many countries, including developed countries such as Australia, the United Kingdom and the United States.…”

Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes

“…ED crowding is a problem that affects health care systems in many countries, but the cause of this phenomenon is still controversial. Many studies have linked ED crowding with the tendency of patients to visit EDs for symptoms or conditions that could be managed by a general practitioner [ 22 , 29 ], and on the contrary, other researchers have considered this point of view as simplistic, because it does not address the multidimensional and complex causes of the problem [ 30 ]. To limit adverse consequences caused by ED crowding and to address the problem, national guidelines have been defined in many European and American countries [ 23 – 25 ].…”

“…To limit adverse consequences caused by ED crowding and to address the problem, national guidelines have been defined in many European and American countries [ 23 – 25 ]. In some cases, policies and protocols have been adopted to solve this problem, and their impact has been evaluated by the literature [ 29 ].…”