104 To achieve 95% of inpatient definite care (IDC) within 24 hours among general medicine patients who are waiting for inpatient beds for more than 10 hours in Tan Tock Seng hospital (Singapore) emergency department
Year: 2025
Type: conference-paper
Abstract: Introduction The Department of General Medicine (GM) at Tan Tock Seng Hospital (TTSH) Singapore is responsible for managing high number of patients that have presented to the Emergency Department (ED) and require admission to the hospital wards for further treatment. 1 The hospital has faced challenges in maintaining acceptable waiting times for inpatient beds and the delivery of definite care due to periodic surges in patient flow. This situation has raised concern of patient safety while lodging in ED for inpatient beds.2 Shortage of dedicated personnel and lack of clinical workflow during COVID-19 pandemic had prevented timely reviews of GM patients in the ED, thus a subset of GM patients waiting in ED did not receive inpatient definite care (IDC) within a 24-hour time frame.The hospital’s previous electronic medical records system was inadequate for the inpatient team to monitor the status of patients and to track waiting times efficiently. This limitation had hampered the ability to prioritize patients needing urgent care.In response to these challenges, the Department of GM is tasked with the critical function of reviewing patients in the ED who are planned for admission. The overarching goal is to ensure that at least 95% of GM patients who wait for an inpatient bed for more than 10 hours receive IDC within a 24-hour window.Strategies and Methodology From the outset of November 2023, a dedicated team from Acute Internal Medicine Service (AIMS) is assigned the responsibility to review GM patients in ED who are planned for admission. The team comprises of a GM consultant, a registrar, three medical officers and a house officer. The following strategies are implemented to ensure delivery of IDC without delay.Morning Chart Review- Medical and house officers do a chart review on the EPIC system (the upgraded electronic medical record platform launched in August 2022) and compile a list of GM patients waiting in ED for IDC at 7 AM on weekdays.Same-Day Evaluation- GM patients whose projected waiting time in ED is expected to reach 24 hours by 5 PM are reviewed by consultant on the same day. The rest of the patients who have waited for more than 4 hours in ED are to be reviewed by at least a medical officer.Early Definitive Management Plan- Majority of the blood and urine investigations can be ordered and dispatched from ED. Urgent radiological investigations including X rays, computed tomography scan, magnetic resonance imaging, ultrasound can be performed in ED after discussion with radiologist. Nursing task orders and procedures such as regular vitals, conscious level chart and capillary glucose monitoring, female urinary catheterisation, wound dressings, nasogastric tube insertion and colostomy bag change can be supported by nurses in ED.Acute Care Prioritization- Patients who require more acute care are prioritized and these cases will be escalated to registrar or consultant, irrespective of their waiting time in ED.On-Call Assessment- Dedicated on-call medical officers are assigned to review patients who have waited for more than four hours during the after-office hours of 5 PM to 8 AM the next day.AIMS Ward Admissions- GM patients who are stable and likely to be discharged within 72 hours are assessed for potential admission to the AIMS ward, contingent on meeting AIMS admission criteria.Communication Roster- A roster details the GM ED review team is made available on the hospital portal to facilitate communication between ED staff and GM team.Results Abstract 104 Figure 1Percentage of GM patients who have waited for more than 10 hours and have received IDC within 24 hours in Year 2024. Data collected from TTSH healthcare performance officeLessons Learned Effective coordination between the GM team and ED team is imperative. ED nursing and medical staff must promptly communicate any significant changes in a patient‘s clinical status to the GM team. A well-defined clinical workflow is essential for ensuring timely assessment of patients in the ED. Sustainability poses a challenge due to fluctuating influx of patients. Therefore, it is crucial to allocate sufficient manpower to the GM team reviewing patients in ED figure 1.Benefits Implementing IDC within the ED for GM patients can improve patient safety by identifying individuals at risk of clinical deterioration and enabling early execution of appropriate management plans. 3 It also facilitates the identification of those eligible for discharge directly from the ED with appropriate follow-ups, thereby reducing hospital bed occupancy level.4 It may decrease the length of hospital stay as definitive management plans and necessary investigations can be arranged and executed from the ED.4 References Lateef A, Lee SH, Fisher DA, Goh WP, Han HF, Segara UC, Sim TB, Mahadehvan M, Goh KT, Cheah N, Lim AYT, Phan PH, Merchant RA. Impact of inpatient Care in emergency department on outcomes: a quasi-experimental cohort study. BMC Health Serv Res. 2017 Aug 14;17(1):555. DOI: 10.1186/s12913-017-2491-xLiew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003 Nov 17;179(10):524–6. DOI: 10.5694/j.1326-5377.2003.tb05676.xLaam LA, Wary AA, Strony RS, Fitzpatrick MH, Kraus CK. Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. J Am Coll Emerg Physicians Open 2021 Mar 2;2(2):e12401. DOI: 10.1002/emp2.12401Schuetz P, Hausfater P, Amin D, Haubitz S, Fässler L, Grolimund E, Kutz A, Schild U, Caldara Z, Regez K, Zhydkov A, Kahles T, Nedeltchev K, von Felten S, De Geest S, Conca A, Schäfer-Keller P, Huber A, Bargetzi M, Buergi U, Sauvin G, Perrig-Chiello P, Reutlinger B, Mueller B. Optimizing triage and hospitalization in adult general medical emergency patients: the triage project. BMC Emerg Med. 2013 Jul 4;13:12. DOI: 10.1186/1471-227X-13-12
Authors: Lip Hong Tan, Noe Cangco
Institution: Tan Tock Seng Hospital
Language: English
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W4410523816