Singapore hospitals find new ways to cope amid wave of Covid-19 cases

Alexandra Hospital’s Staff Nurse Sheena Sivakami removes her PPE at the temporary de-gowning area in the screening tent. PHOTO: ALEXANDRA HOSPITAL

SINGAPORE - As public hospitals here grapple with the surge in Covid-19 patients, two of them have new initiatives to ensure their emergency departments (ED) can cater to patients with urgent needs as much as possible.

The programmes are aimed at preventing unnecessary ED visits by those who need help but do not have Covid-19 or urgent issues.

Alexandra Hospital (AH) has a new hotline for discharged patients while Ng Teng Fong General Hospital (NTFGH) has a new ED care management scheme.

These triage schemes, piloted around August last year, are aimed at frail, elderly persons who frequently visit their EDs. The goal is to decongest the EDs and save beds.

EDs have always been crowded, but the pandemic has made the situation much worse. As at Monday (Oct 11), 1,698 Covid-19 patients are warded in various hospitals, with 308 needing oxygen supplementation and 42 in intensive care.

To free up hospital capacity, hospitals have, for instance, postponed less urgent operations and are actively discharging patients or shortening stays when possible.

AH's hotline is for discharged patients to call, send an SMS or e-mail for help with post-discharge medical matters, instead of returning to its ED, which is called a 24-hour Urgent Care Centre, or UCC, as it handles medical emergencies but not major trauma cases like heart attack or acute stroke.

Care managers manning the hotline in the Virtual Care Centre are from the existing transitional care team that also helps with coordinating community services for patients who are ready to be discharged. They get about 50 calls a month on average.

With the new centre, discharged patients can gain access to a doctor, or be directly re-admitted to a ward, thus bypassing the UCC.

"Having access to a doctor after discharge and being able to admit patients directly from home to the hospital ward is a totally new initiative," said Dr Satya Gollamudi, AH's head of medical services, who leads the team that piloted the scheme.

The aim is to prevent unnecessary readmissions to the hospital's UCC, he said.

The scheme has helped AH prevent 37 per cent of readmissions from August last year to September this year, said Dr Gollamudi.

"These are the cases that, if we don't intervene, would have gone back to the ED," he said.

This is because these elderly patients - more than 80 per cent of AH's inpatients are above the age of 65 - would do so to get help for problems they develop a few days or weeks after discharge.

"Until now, most admissions happen through emergency departments. There is no other way to admit to inpatient wards," said Dr Gollamudi.

NTFGH now has an ED case manager under a new programme started by emergency medicine consultant Colin Ong. It gives seniors (who do not have Covid-19 or an emergency) access to the care they need such as speech therapy, without having to be admitted.

These are the frail, elderly patients who go to the ED for various reasons such as a mild infection, or they may have had a fall but do not have a fracture that needs to be fixed, or a medical condition that caused the fall, said Dr Ong.

He added that the new programme has helped prevent 30 per cent of readmissions from August last year to June this year.

Intervening at the ED stage is a win-win situation because elderly patients generally do not do well when hospitalised, said Dr Ong.

"They may decline physically and mentally while being warded. This helps to reduce the falls and infections, and we save a bed," he said.

The case manager, assistant nurse clinician Kamala Velu, can link these patients at the ED directly to allied health professionals and community service providers, or arrange for home care, among other things.

She said she has arranged for medical transport, meal delivery, community nursing and social support for a patient with low vision who was otherwise be frequently admitted to hospital.

Dr Ong and Ms Kamala have experience in this area, having made home visits some years ago to patients discharged from the ED. That programme was dropped because it proved too costly.

The NTFGH ED care management team, which has trained a group of doctors and nurses to help with the screening process, currently has one case manager and continues to look for more.

AH is also planning to grow its virtual care centre and extend the operating hours of the hotline (9am to 5.30pm, Monday to Friday) to 9pm next year. There are also plans to extend this service to patients at outpatient clinics, the community in the Queenstown area and later, in the western region.

"We want to cast a wider net to avoid unnecessary ED visits. That's the whole point of this programme," said Dr Gollamudi.

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