A & E DEPARTMENTS (Screening of emergency cases)

Dr Koh Lam Son asked the Acting Minister for Health what are the reasons for employing a nurse rather than a medical officer to screen emergency from non-emergency cases at the Accident & Emergency Departments.

The Acting Minister for Health (Mr Yeo Cheow Tong): Mr Speaker, Sir, nurses are employed to screen patients at the Accident & Emergency Department as the screening process is a relatively routine function which nurses are competent to undertake. This relieves such duties from the doctors who can then devote their time attending to the true emergency cases.

Screening is done by asking the patient for details of his or her symptoms and by visual assessment of the general condition of the patient. Where necessary, the nurses will measure the patient's temperature, pulse and blood pressure.

The nurses employed for screening are experienced nurses who have been trained specifically and provided with guidelines to distinguish emergency from non-emergency cases.

There is also close supervision of the nurses' work by the doctors. Should they encounter any doubt or difficulties in screening, they would immediately consult the doctors or refer the patients to them.

Dr Koh Lam Son: Sir, would the Acting Minister not agree that, in fact, the screening of an emergency case from a non-emergency case can sometimes require great diagnostic skills? And what the nurse is doing is a spot diagnosis. If it leads to a case that is missed out, would it not be difficult for the Minister to defend his statement that the doctor was not present to sort out the problem?

Mr Yeo Cheow Tong: Mr Speaker, Sir, where the case is highly complicated, the nurses would then, for the sake of safety, err on the side of safety and refer the case to the doctor. The guidelines are fairly straightforward. Perhaps it will be useful for Members to know what are considered emergency cases and what are not considered emergency cases.

Emergency cases would include cases where the illness or injury could end in death or serious complications would arise if it is not treated immediately. And generally this would involve acute or sudden onset, for example, of bleeding, severe or increasing pain, or a change in the vital signs of life, like loss of consciousness or difficulty in breathing. A condition that a patient has been suffering for a long time or is currently under treatment which suddenly takes a turn for the worse would also constitute an emergency. Examples of emergencies would be trauma emergencies which are quite straightforward, eg, fractures and dislocations, head injuries, deep cuts or large wounds on the body, severe bleeding and severe burns or scalds.

It would also include minor injuries such as bee and insect stings and non-trauma emergencies such as heart attack, acute appendicitis, vomiting of blood, passing blood in the stool or urine, high fever, severe allergy and poisoning. So it is very broadly encompassing and it is very unlikely that any serious case or true emergency case would not be caught under such guidelines.

Dr Koh Lam Son: Sir, has there been any emergency case that has been misdiagnosed by a nurse and as a result led to delayed treatment by the doctor?

Mr Yeo Cheow Tong: The information given to me so far is no.

Dr S. Vasoo (Bo Wen): Sir, does this service justify the need for an increase in the A & E fees?

Mr Yeo Cheow Tong: Mr Speaker, Sir, emergency treatment is a very important treatment for Singaporeans. And it is the priority and the objective of the Ministry to ensure that such cases are treated correctly. Over the years, we have been making strenuous efforts to try to improve the level of service. For example, if we just look at the number of doctors provided to the A & E departments, in 1981, just five years ago, only 44 doctors were posted to all the A & E departments in our hospitals. In 1986, this number has increased to 60, which represents about an increase of 36%.

In the meantime between 1981 and 1986, the patient load has dropped by about 10%, which means that in actual effect the number of doctors serving the patients has increased by about 50%. What has that resulted in? It has resulted in a tremendous reduction in the waiting time for patients. Previously, the waiting time for the patients would average about 45 minutes. Today, the average waiting time has gone down to 12 minutes. In the past, during the peak period, over 30-35% of the patients would have to wait in excess of one hour before treatment. And it was not unusual for patients to wait between 1 1/2 - 2 hours. Today, only one out of 20 has to wait for more than an hour and normally it is just slightly over an hour.

In terms of the quality of the doctors who have been posted to the A & E departments, this has also increased very significantly. Previously, there was only one consultant in all the A & E departments in Singapore. Now we have five consultant doctors posted to the A & E departments. All this represents a tremendous allocation of resources to the A & E Department to ensure that the patients there are well looked after.

In terms of the fees, the last time the A & E fees were increased was in 1978, a full nine years ago. I think Members and Singaporeans would recognize that in the last nine years costs have gone up very significantly, even if the resources made available to the A & E had not increased. I think Singaporeans in situations where they need emergency treatment very urgently would appreciate that improving the services would definitely result in an increase in costs. I am sure they would not mind paying a little bit more to ensure that their lives are well taken care of in an emergency.