locum lokun life: bed occupancy rates + corridor beds + sweat rash season

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This is part of an ongoing monthly series capturing the highs, low (and everything in between) in my life as a freelance doctor working in Singapore. If you’re interested in finding out about medical/non-medical careers or getting answers to doctoring-related questions, check out my Chasing Careers series!

First things first, a warm welcome to the new batch of HOs who’ve joined the M0HH sweatshop! Hope your first month’s been going alright so far and remember to take care of yourself, your friends & your sanity. If it hasn’t, I genuinely hope things get better soon :’)

Earlier this month, the WHO finally announced that COVID-19 was no longer a ‘public health emergency of international concern’. That’s a lot gobbledygook to say that we can collectively calm down about COVID.

Let’s embrace the fact that COVID is the new Influenza – it isn’t going anywhere anytime soon, but with COVID having just a 0.1% mortality in Singapore, at least it isn’t anything as deadly as SARS (9.56%) or the bird flu (60%).

And at any rate, our local healthcare system has bigger things to worry about, like overflowing hospitals, corridor beds and 100% bed occupancy rates.

goodbye COVID, hello BOR 100%

So, what’s BOR? It stands for Bed Occupancy Rate, and this is how it’s calculated:

[Number of beds occupied by a patient for curative care]/[Number of beds available for curative care in the hospital], multiplied by 365 days (or any defined period of time), then by 100 to obtain the percentage.

Research has found that ‘although there is no general consensus about the “optimal” occupancy rate, a rate of about 85% is often considered a maximum to reduce the risk of bed shortages.’

Below is a chart released by MOH, which trends a full week of BOR data across various public hospitals in Singapore (you can view additional data at this link).

According to the UK’s National Institute for Health and Care Excellence (NICE), a high BOR has plenty of implications on healthcare outcomes, particularly for patients admitted for acute conditions (rather than electively for simple procedures/operations, etc.):

Overall, the evidence suggested that, in general, any increase in occupancy leads to an increased risk of adverse patient outcomes including mortality (in-hospital, 7-day and 30 day), avoidable adverse events reported as hospital-acquired infections (Clostridium difficile infection), length of stay, 30 day readmission and delays in admission for patients waiting in ED.

The committee noted that the observational studies did not fully account for confounding factors such as seasonality, independent of occupancy. The committee concluded that high levels of occupancy were likely to result in harm, particularly for patients on an emergency admission pathway rather than elective care pathways. In setting an optimal occupancy rate, hospitals would need some flexibility in choosing a safe upper limit which needed to take into account case mix, variations in the proportions of elective and emergency admissions, and the ability of community services to respond to timely hospital discharge.

Emergency and acute medical care in over 16s: service delivery and organisation

From a hospital administration viewpoint, seeing how most of the hospitals are hovering well above the 85% ‘ideal maximum BOR’, it’s a hot mess. From a patient’s or doctor’s viewpoint, it’s also a hot mess.

overflowing wards

Beyond viewing BOR as just a statistic to be managed, what a high bed occupancy rate really means for doctors and patients is:

  • The wards are always packed!! Whenever we discharge one patient, one (or two) more appear
    • This puts a significant strain on already-stretched manpower, from doctors to nurses, to social workers/allied health staff
    • Worsening workplace morale, exhaustion, poor pay and a lack of mental well-being safeguards are the recipe for staff burnout
    • It’s no surprise that nurses are quitting in droves, and seeking out better working conditions elsewhere. 7.4% of local nurses resigned in 2021, marking a five-year high
  • The lack of beds in the wards translates to longer waiting times in the emergency departments
    • The Straits Times reported on 22 Apr 2023 that ‘the median wait time has gone up over the past fortnight, from five hours to 7.2 hours’ and they found that ‘in some cases, patients can wait up to four days to get a bed’
  • Like how salespeople have to hit KPIs, the hospital administration pressures the various Heads of Departments to discharge more patients (to free up beds), who in turn pressure the consultants, who in turn pressure junior doctors
    • Back when I was still working in public hospitals, there were many days when our bosses would tell us that the Emergency Department was overflowing with patients waiting to be admitted, and that we needed to push for discharges to free up inpatient beds
    • When we say ‘push for discharges’, it means (1) convincing families to take their relatives back at their earliest convenience and (2) cramming out all the discharge paperwork and planning outpatient appointments before noon each day
  • Sometimes, there aren’t enough beds inside the cubicles (which usually fit 4-6 B or C-class patients), so the patients are relegated to corridor beds:
POV: You’re a patient in a corridor bed in TTSH

It’s not a pissing competition to see who has it worse – healthcare staff or patients. A high bed occupancy rate, coupled with a never-ending stream of patients walking or being wheeled into the Emergency Room, isn’t doing anyone any favours.

Both staff welfare and patient outcomes arguably take a hit, so what can be done?

I was recently catching up with two long-time med school friends. One of them hit the nail on the head when she said that “Even if we open up new hospitals, it doesn’t mean the current hospitals will get less crowded. More patients will appear out of thin air, I don’t know where they’re appearing from.”

This issue is certainly related to and exacerbated by the ageing population, with the percentage of hospital patients (65 and above) rising from 39% in 2019 to 43% in 2022.

Looking ahead, the government has devoted a significant budget to various preventive health and chronic disease management programmes such as Healthier SG, Healthy 365/Lumihealth, Live Well, Age Well, etc.

Additionally, there are plans to continue utilising the multiple transitional care facilities (TCFs) that were established during COVID as step-down facilities, to alleviate the existing bed crunch. They will ‘house medically stable patients from public hospitals waiting for long-term care arrangements, such as home or nursing home care.’

It remains to be seen where and how they’ll materialise more healthcare staff to run these places, but if they pay freelance doctors/nurses the right amount, we might collectively come out of the woodwork to help out. Or maybe they’ll just spread the existing pool of public sector doctors/MOPEXes even more thinly, creating further manpower crises. Who knows?

global warming = RIP your skin

On a more lighthearted note, it’s ‘why do I feel like my skin is melting when I step outdoors at 3pm’, a.k.a. sweat rash season! Is there any way to relocate Singapore closer to the North Pole?

In my GP clinic, I typically see 2-3 cases of sweat rashes per week, typically in younger gym goers/runners. But ever since the recent heat wave hit at the start of May, I’ve seen a 3-fold increase (not exaggerating) in the number of patients coming in with eczema flares, sweat rashes or headaches after being outdoors for too long.

I rarely see elderly come in with complaints about sweating, but in the past week alone, I saw 3 such cases, and plenty more complaining about the absolutely unbearable heat. The elderly seem particularly affected, so I always take pains to nag them about adequate hydration, using umbrellas and wiping their skin after sweating.

Sitting in the clinic all day can sometimes get boring, so it’s interesting to observe small-scale epidemiological trends and correlate them with current happenings (I reckon I wouldn’t have noticed it if I were a hospitalist).

Anyway, here’s a PSA to always slather on a ton of sunblock if you’re headed outdoors – not just during hot periods of the year, but all year round and whenever the sun is out – and bring a large water bottle with you at all times so you don’t become a shrivelled, sun-damaged prune with spotted skin!

That’s all for this month’s post! Next month, I’ll continue rambling about Singapore’s ageing population, how more elderly living alone have been dying undetected and what ‘healthspan’ is all about (and how it differs from lifespan).

Here’s my latest addiction, American Teenager by Ethel Cain. It was written as an expression of her frustration with ‘all the things the American teenager is supposed to be but never had any real chance of becoming’ (kinda sounds like Singaporean teens too doesn’t it?):

I’ve listened to this >130 times in the past month…

Grew up under yellow light on the street
Putting too much faith in the make believe
Another high-school football team
The neighbor’s brother came home in a box, but he wanted to go so maybe it was his fault
Another red heart taken by the American dream

As always, thanks to my loyal readers, and be sure to follow my Insta or like my Facebook page to stay up to date with all my upcoming posts. Next month promises to be a bumper crop, with 4 posts planned (including a special one for my 26th birthday)!


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