Impact of health care system interventions on emergency department utilization and overcrowding in Singapore

BACKGROUND Public emergency departments (EDs) in Singapore were facing increasing attendances (visits) with frequent overcrowding in the 10 years from 1975 to 1985. Over the next 12 years a series of social interventions were carried out to minimize "unnecessary" attendances at these EDs. AIMS This paper reviews the various interventions carried out on ED utilization to determine their impact and usefulness. METHODS Emergency and non-emergency attendances at the six main public EDs were analysed over the 32 years of the review and especially just before and soon after the application of four major interventions relating to use of EDs, including: (1) public education campaigns, (2) financial disincentives, (3) redirection to primary health care centres and (4) use of alternative clinics. RESULTS The 12-year period of social interventions resulted in a fall in the proportion of non-emergency patients using the EDs from 57% to 18%. Public education campaigns each resulted in a fall in inappropriate attendances of 27% to 67%. Financial disincentives were able to demonstrate an impact if they were significant and resulted in a heavier fiscal cost to the patient than if available primary health clinics were used. Redirection of non-emergencies away from EDs resulted in significant public relations issues with only mild decreases in non-emergency attendances. Alternative clinics may provide some respite if actively promoted by ED staff, but are able to generate their own separate patient clientele. CONCLUSIONS Public education and financial measures that seek to change the pattern of ED utilization in a community must go hand in hand with an easily accessible primary health care system for best effect. Co-ordination of such efforts requires active support from all levels of the health service and political leadership. An active feedback loop is needed for better outcomes management.