There is variability in the characteristics and capabilities of EDs in Singapore. The differences appear to be dependent primarily on whether they are in public or private sector institutions.
Similarities amongst EDs in Singapore appear to be for patient census (> 20,000 per annum), which is considered reasonable by most countries elsewhere, a contiguous layout with medical and surgical emergencies seen in one area, being open and accessible to the public 24/7 and generally having access to a wide range of medical specialists across the various hospitals.
Differences amongst Singapore EDs appear to be primarily between those in the private versus the public sectors in terms of patient census (30,000 or less patients per annum in private sector hospitals versus at least 60,000 patients in public hospitals, which has major implications on issues such as floor space, size of facility and trained manpower required to manage the volume load in public EDs), staffing by emergency medicine board-certified physicians and emergency trained nursing staff (some of whom have also undergone specialty training in Emergency Nursing), ED bed complement and inpatient admission rates (10% or less in the private sector compared to the generally greater than 25% in the public sector). This may reflect a higher patient acuity in the public sector population. As a result of a series of public education programs conducted in public institutions over the previous 2 decades, and other social initiatives, there has been a significant shift in the case mix of public sector EDs in Singapore such that patients with low-acuity complaints generally do not visit public EDs
]. Such a shift would be likely to result in higher acuity patients being seen, resulting in more time spent on patient care per patient seen and a longer stay in the ED prior to a decision on admission or discharge. Length of stay also appeared to be generally much shorter in private EDs than public ones. This may be owing to a lower patient acuity or lower overall census in private EDs, or it may suggest an extremely rapid process of care in these private institutions.
There is currently no congregation of public or private hospitals in locations of particular economic or social status. Being a very small and compact country, the distribution of hospitals is fairly even in relation to the population spread and is generally not seen as particularly influencing demand in specific individual hospitals (Figure
Geographical map of Singapore with emergency department locations marked.
Taken together, our data would suggest that if one were to characterise public sector EDs in Singapore, they could be described as having a large number of beds; large numbers of high-acuity patients with a significant inpatient admission rate that contribute a major proportion of hospital inpatients; high public emergency ambulance coverage; staffing by emergency medicine board-certified physicians; being well-equipped with monitors, ventilators and respiratory isolation units; and making reasonably good use of information technology. This would place Singapore public sector EDs as being equivalent to some of the best similar facilities in countries such as the US
Conversely, our data suggest that private sector EDs may be seen as having small numbers of beds with a relatively low-acuity patient population in significantly smaller numbers that contribute a small proportion of hospital inpatients and that is seldom serviced by emergency ambulances. In addition, such private EDs appear to be staffed by doctors who utilise technology more sparingly in the daily care of patients. This lower technology care provided may not truly reflect the good work that is carried out in private sector EDs. These private EDs have been able to demonstrate shorter turn-around times, which may reflect greater efficiencies in process management and more judicious use of resources (albeit with lower patient volumes and likely lower acuity). A conclusion about the quality of emergency care cannot be made because this study, after all, did not compare patient outcomes.
A future study may be useful in examining quality differences between private and public EDs. One of the consequences of being perceived as a low-performance ED may be a greater reluctance on the part of public emergency ambulance services and patients to want to use them for emergency care. In addition, national emergency and disaster planners may doubt the ability of smaller private sector EDs, and hence, private hospitals, to be able to handle mass casualties and major disease outbreaks. This would be doing a major disservice to the large number of excellent physicians who had previously been captains of the profession in the public sector and have subsequently moved to private sector institutions so as to manage a different lifestyle. At the same time, it is important to channel resources where they are most needed and to ensure that every ED is held to a similar national standard, no matter if it is publicly or privately operated.
There is a need to examine why the wide variability exists between public and private sector EDs in Singapore and how this variability affects patient care and patient outcomes. This survey was not structured to examine such reasons. Since the data were collected with reference to the year 2007, it is possible that some of the differences have been reduced over the last few years. For public hospitals, we know that one new major hospital has begun operations in 2010 and is managing a reasonably large patient load in the moderate range. The distribution of information and other technology could have evened out over the last few years. Anecdotally, emergency medicine board-certified physicians used to only be at public-sector hospitals, but in recent years have begun gradually moving into private sector EDs. Our national inventory should be repeated at regular intervals and also include quality indicators for this to be benchmarked and then set targets for future improvement.
There are other notable findings. One is the relatively low length of stay, accompanied by the finding of only two EDs reporting themselves to be overcapacity. EDs in other developed countries have been struggling with issues related to overcrowding
]. Singapore faced a similar problem, and, in recent years, has implemented multiple health-care system interventions and public education programmes to reduce ED crowding and optimise ED utilisation for emergency complaints. A study in 2008 found that over a 12-year period following the implementation of these interventions, non-emergent use of the ED had fallen from 57% to 12%
]. That the interventions have had their intended impact on reducing non-emergency attendances is suggested by our finding that only two EDs self-reported to be overcapacity. The concern about overcapacity may, however, reflect access block issues in these institutions. These system interventions can still be instructive to other countries, such as the US, that experience severe overcrowding in their urban EDs
Another finding is that technological resources are generally available. It is interesting to note the evolution of technology in Singapore EDs. Cardiac monitoring facilities had been available in most EDs for many years. These were initially mainly in the form of stand-alone ECG monitors placed next to patients while awaiting transfer to other areas of hospitals. In the 1990s, dedicated, fixed ECG monitors were made available in all resuscitation bays of the largest hospital and gradually extended to all public EDs in the country. Telemetry was also gradually introduced to public EDs in the 1990s. A seven-bedded chest pain unit was started at one of the EDs in 1998. Such units are now available in at least three public EDs as part of emergency observation units.
A CT scanner was initially available within only one ED in the 1990s. The 2000s saw the use of hospital CT scanners being made available to all public EDs. Currently, at least six EDs have CT scanners either within or just adjacent to their premises. In some hospital EDs, residents discuss the patient with a consultant with admitting privileges to the institution and then proceed to make arrangements with the radiology service for such a resource to be made available to the patient.
Mechanical ventilators are available in the resuscitation areas of all public EDs as part of national disaster preparedness. This relates to public perception for the need for prompt management of disaster casualties, especially after the multiple terrorist incidents that have occurred on the international scene over the last 1 ½ decades and the increasing reporting of major disasters such as earthquakes, tsunamis and technological disasters. These EDs have learnt to become familiar with the use of ventilators in the management of sick patients on a daily basis.
Respiratory isolation facilities have become available in public EDs and in a few private institutions after the national experience with the outbreak of the Severe Acute Respiratory Syndrome in 2003. Such units are not readily available in most EDs in the region or even in Asia, except in communities keenly aware of the need for such facilities to contain, isolate and minimise the spread of communicable diseases brought into the department by infected patients. The absence of critical services or equipment in particular would usually mean that patients would not be denied these services, but that secondary referrals or transfers to facilities providing such services would be arranged.
EM is developing around the world, and Singapore is among the few countries that have clearly developed and established the specialty of EM for over 2 decades. Leaders in Singaporean medicine have suggested that Singapore has a role in promoting global health
]. Indeed, Singapore is well poised from a number of different perspectives to influence international health development, especially since it has an efficient health-care system that provides high-quality universal health care while spending just 3-4% of its gross domestic product on health
]. Our findings about the advanced and organised nature of EDs in Singapore also provide support for Singapore having a major role in the advancement of EM. For example, it has been suggested that resource-poor settings may benefit from preferential training of emergency physicians capable of treating all emergencies
]. For countries with nascent emergency care systems, Singapore could offer a useful model for EM workforce studies, residency training curriculum, and ED benchmarking and comparisons. Countries that have a strong private sector may also learn from the Singapore experience when it comes to coordinating and comparing delivery of care by public and private EDs.
Our study has several potential limitations. We recognise that this is an initial study with descriptive statistics, but it provides new information to guide efforts to advance emergency care in Singapore. The survey also did not examine quality of care issues, specifically the quality of care between EDs in pubic and private sectors. Such a comparison is very important, but would have required a different format of investigation and would have had to be prospective over a significant time period. Such a study needs to be conducted at intervals of at least 5 years, with benchmarking of targets to be achieved in specific instances.
Another limitation is that the survey used is not validated. To our knowledge, a validated instrument to assess EDs worldwide does not exist. Questions from our survey have been used in studies of US EDs and also have been used successfully in several other countries, ensuring usability and that the wording of questions was appropriate for diverse contexts
In addition, there is the limitation that this study relies on self-reported data. ED administrators were asked to supply data when available. When exact figures were unavailable, ED physician-administrators provided their closest approximation. As the survey was anonymous, with 100% participation, we do not suspect a systematic bias in the responses.