Emergency department crowding in Singapore: Insights from a systems thinking approach.

Abstract

Objectives

Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care.

Methods

The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied.

Results

The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created.

Conclusion

Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options.

Department

Description

Provenance

Citation

Published Version (Please cite this version)

10.1177/2050312116671953

Publication Info

Schoenenberger, Lukas K, Steffen Bayer, John P Ansah, David B Matchar, Rajagopal L Mohanavalli, Sean Sw Lam and Marcus Eh Ong (2016). Emergency department crowding in Singapore: Insights from a systems thinking approach. SAGE open medicine, 4. p. 2050312116671953. 10.1177/2050312116671953 Retrieved from https://hdl.handle.net/10161/22822.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.

Scholars@Duke

Matchar

David Bruce Matchar

Professor of Medicine

My research relates to clinical practice improvement - from the development of clinical policies to their implementation in real world clinical settings. Most recently my major content focus has been cerebrovascular disease. Other major clinical areas in which I work include the range of disabling neurological conditions, cardiovascular disease, and cancer prevention.
Notable features of my work are: (1) reliance on analytic strategies such as meta-analysis, simulation, decision analysis and cost-effectiveness analysis; (2) a balancing of methodological rigor the needs of medical professionals; and (3) dependence on interdisciplinary groups of experts.
This approach is best illustrated by the Stroke Prevention Patient Outcome Research Team (PORT), for which I served as principal investigator. Funded by the AHCPR, the PORT involved 35 investigators at 13 institutions. The Stroke PORT has been highly productive and has led to a stroke prevention project funded as a public/private partnership by the AHCPR and DuPont Pharma, the Managing Anticoagulation Services Trial (MAST). MAST is a practice improvement trial in 6 managed care organizations, focussing on optimizing anticoagulation for individuals with atrial fibrillation.
I serve as consultant in the general area of analytic strategies for clinical policy development, as well as for specific projects related to stroke (e.g., acute stroke treatment, management of atrial fibrillation, and use of carotid endarterectomy.) I have worked with AHCPR (now AHRQ), ACP, AHA, AAN, Robert Wood Johnson Foundation, NSA, WHO, and several pharmaceutical companies.
Key Words: clinical policy, disease management, stroke, decision analysis, clinical guidelines


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