Background: High hospital occupancy is a ubiquitous problem worldwide. Singapore General Hospital (SGH) being the largest tertiary hospital in Singapore, sees a large number of attendees come through its Emergency Department (ED) daily 1,2. With silver tsunami on the horizon and rising life expectancies around the world, we are facing higher healthcare complexities and stress on scarce healthcare resources. This has led to more patients with multiple co-morbidities seeking acute care at the ED, being hospitalized, and increasing pressure on bed occupancy rates. This situation was exacerbated by the severe acute respiratory syndrome coronavirus pandemic in 2021 which consumed even more healthcare resources. This has led to more patients waiting in the ED and longer waiting time for inpatient hospital beds. Here, we describe our internist-led ambulatory model of care that aims to address the current public hospital needs in Singapore, improve the patient journey, and guide resource allocation necessary to fully develop acute ambulatory care moving forward.
Methods: To cope with the surge in medical patients being lodged in ED, and to ensure early medical care gets delivered, the department of Internal Medicine formed an acute ambulatory care team (ACT). This is an internist-led triage team that serves to clerk and manage all the medical patients admitted to Internal Medicine, lodging in the ED. For patients identified to be acutely unwell, treatment will be instituted promptly and they will be given priority for inpatient bed allocation. Patients with stable ambulatory care sensitive conditions and low National Early Warning Score (NEWS) will be promptly assessed, treated, and discharged within the same or the next day. Patients get to continue their treatment at home and/or follow up in ambulatory clinics, thus freeing up hospital bed resources for the sicker, more deserving patients. To further enhance these efforts, we formed a collaboration with ED, bed management unit, and family medicine community care colleagues to discuss patient bed allocation and discharge planning. The discussion was conducted through a secure platform known as Tigertext(TT).
Results: 388 patients were discharged by the ACT during the period of 1st February to 31st May 2022. 47% of them were aged 65 years and above, with a median age of 64 years old. Two-thirds of them (63%) were females. 80% were self-referred to the ED. 11% were triaged as priority 1 status and 79% were of priority 2 status based on ED initial triaging. Safety outcome measures include 30-day mortality, unplanned ED re-attendance, and readmission rates. There was only one expected mortality within 30 days. The ED re-attendance rates were 3%, 3%, and 7% for 72 hours, 7 days and 30 days respectively. The readmission rate was 10% at 30 days post-discharge, compared to 13% for IM patients admitted to the medical wards. The top discharged diagnoses fall within the ambulatory care sensitive conditions (ACSC), which includes symptoms based diagnoses like dizziness, chest pain, and chronic conditions such as hypertension, fluid overload, diabetes, and its complications.
Conclusions: The formation of ACT was opportunistic but also timely during the COVID-19 pandemic. It gave us an opportunity to rationalize our resource allocation, by providing early specialized medical assessment and treatment and expediting discharges without compromising care. It also gave us the opportunity to collaborate with BMU on the right-siting of care and reduce inefficiencies related to bed allocation.