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. 2016 Oct 4:4:2050312116671953.
doi: 10.1177/2050312116671953. eCollection 2016.

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

Lukas K Schoenenberger  1 , Steffen Bayer  2 , John P Ansah  2 , David B Matchar  3 , Rajagopal L Mohanavalli  4 , Sean Sw Lam  4 , Marcus Eh Ong  5
Affiliations

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

Lukas K Schoenenberger et al. SAGE Open Med. .

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.

Keywords: Critical care/emergency medicine; Emergency Department crowding; causal loop diagramming; modelling; path analysis; policy analysis; systems thinking.

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Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Evolution of total population and ED attendance in Singapore from 2005 to 2011.
Figure 2.
Figure 2.
Evolution of EPs and patients/EP in Singapore from 2005 to 2011.
Figure 3.
Figure 3.
Core model structure of ED crowding.
Figure 4.
Figure 4.
Expanded model structure of ED crowding.
See this image and copyright information in PMC

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