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ED congestion: what gives?

I landed myself in an Emergency Department (ED) again several weeks ago because of acute cardiorespiratory symptoms. I was so close to not presenting myself to the ED that day just because it was a Saturday afternoon, right at the beginning of the flu season. Having analysed ED attendance pattern in my daily work previously, I quite naturally expected an absolutely congested ED given the circumstances. And I was not proven wrong. So much so that when I was wheeled into the ED, the Assistant Medical Officer had to place me right at the doorway because it was packed to the brim. You don’t have to read my story to know that I am telling you the truth about the reality of EDs across this country. Our EDs are congested and I sure hope it is not being a deterrent for people who need its services the most.

Basic facts about ED in public hospitals

In Malaysia, all Ministry of Health (MOH) hospitals have Emergency Departments with varying levels of care as below:

  • Level I: Provided by non-specialist hospitals.
  • Level II: Provided by minor specialist hospitals with daily patient attendance between 150-200
  • Level III: Provided by major specialist hospitals with daily patient attendance between 200-300
  • Level IV: Provided by state hospitals and Hospital Kuala Lumpur with daily patient attendance exceeding 300

Every patient that walks through the EDs’ doors are triaged according to the three-level triage system as below (in order of increasing level of resource intensity required):

  • Green: Non-critical conditions which are really non-emergency. (~70% attendance)
  • Yellow: Semi-critical conditions with associated high risks. (20-25% attendance)
  • Red: Critical conditions requiring resuscitations. (5-10% attendance)

In 2017, EDs all over the country attended to a total of 8.01 million patients. That accounts for 38.1% of total outpatient attendance nationwide. According to MOH, the numbers are growing between 2-3% annually. On the other hand, the Auditor-General (AG) 2018 Report Series 1 stated that EDs are generally short of staff by 11.6% to 53.1%. The shortage includes emergency specialists (75.6%-79.5%), medical officers (41.2%-64.6%); assistant medical officers (2.6%-33.9%) and trained nurses (17.4%-67.1%), all of whom are crucial to the emergency services delivery. As a consequence, only 58.7% to 74.5% of patients were able to be treated within four to six hours, while many had to wait longer to secure beds in the wards. The AG report rightly concluded that EDs in Malaysian hospitals are understaffed, overcrowded and underfunded (1).

It is easy to assume based on the AG report that EDs all around the country are congested primarily because of long waiting time attributable to lack of staff, medical equipment and inpatient beds to cater for the ever-growing public demand for the service. But to me, that sounds a lot like attribution bias (2). Personally, I think the report had overemphasised those factors, while it underemphasised other possible systematic causes that have led to the situation at hand, possible root causes. The underemphasised factors are what I am interested in. Healthcare administrators need to seriously look at how the national healthcare system has produced an unintended and unintentional funnelling of patients towards EDs and caused the very problem. An honest introspection may point towards few but very interesting points.

Green Zone (GZ): do we need it?

Non-critical health conditions are largely treated in primary health clinics (Klinik Kesihatan, KK), with some clinics opening up until 10 p.m on weekdays and 1 pm on weekends. But when the KKs are closed, patients with these conditions present themselves to government hospitals’ EDs (please read about how low access fees in MOH facilities may have contributed to this phenomenon, below). Technically, this need not have happened if there is no GZ in EDs in the first place (or if patients acknowledge that their conditions are non-emergency in nature – not within the scope of this post). In other words, 70% of ED patient attendance which collectively require a substantial volume of resources (often at times when EDs are at its lowest capacity i.e. oncall hours) could possibly be avoided. EDs won’t be congested if they’re reserved for real emergencies only.

Although the decision to have GZ in EDs is likely due to MOH’s vision for universal healthcare (powered by its “No Wrong Door Policy”), the appropriateness of providing that care in EDs need to be questioned. Remember, the cost incurred to care for non-critical patients in government hospitals’ EDs is higher as compared to in KKs, even if the eventual treatment and outcome are similar. This is simply because of the higher overhead costs of running the hospitals. Perhaps thinking along the lines of improving public-private partnership with private clinics (beyond the scope of Peka B40), thereby simultaneously increasing the number and availability of primary care providers, might be worthwhile. EDs just cannot function or be treated like KKs without having to bear the risks and unintended negative effects that come along with it.

Lean ED (Green Zone): a vicious cycle

In the last decade, MOH had invested heavily in Lean Healthcare Initiatives. One of the largest and earliest initiatives is in improving the operational efficiency of EDs’ Green Zone (GZ) using lean management tools. This was in response to the growing demand for the services and in an effort to remedy the demand-capacity mismatch so prevalent in EDs’ GZ. Under the initiative, many hospitals had successfully reduced the arrival-to-consultation (ATC) time and the length of stay (LOS) in EDs, commendable achievements indeed. However, soon after, word of mouth about the shorter waiting times in those EDs got out resulting in an increasing number and rate of patients attendance. It seems that the more efficient the EDs’ GZ become, the more demand they generate, and the more they struggle to keep up. The initiative had inadvertently conjured up a vicious cycle.

But, that doesn’t mean that MOH and its staffs should stop improving their services and cease to become more efficient. In fact, they should continue their noble efforts as there is no other way other than to continue to improve. However, simply increasing EDs’ capabilities and efficiency by engaging in improvement initiatives based on the latest trendy management tools to cater to the growing demand for its services without having a clear sense of the problem and all possible outcomes just won’t cut it. An initiative should never take place unless the problem statement is unambiguous, the scope is clear and all risks and benefits associated with it are laid out explicitly. Decisions made based upon such thorough analysis with the engagement of relevant parties may spare MOH unwelcome surprises thus saving it precious ringgit, effort and time.

High value at a low price: an irresistible deal

Perhaps the single most important systematic cause of overcrowding in EDs is the low access fee. In Malaysia, patients only need to pay a maximum of RM5 in order to be registered and subsequently utilise government hospitals’ services (including EDs). This has remained unchanged since 1982 despite an overall increased level of household income nationally. The Malaysian healthcare system, which is rated among the best in the world, literally offers high quality, high-value healthcare services at minimal charges. It is definitely an offer that is hard to resist, given that the other options (e.g. private clinics or private hospitals) are costlier but maybe only marginally superior in quality, if not similar or lower. This has resulted in patients’ lowering their threshold to present themselves to government hospitals’ EDs leading to a greater number of patients’ attendance.

However, simply raising the access fee won’t remedy the problem. The amount of raise, if any, needs to be substantial enough that it produces its intended outcome, which is increasing the threshold at which patients present themselves to EDs (especially GZ) and closing the price disparity between public and private healthcare services (which may lead to a better distribution of patients and sharing the burden of care between the two systems). But, the revised fee structure must ensure that those who are in the lower-income categories are protected so as to not deter them from getting the healthcare services that they need, and those that could afford it pay for the services accordingly. MOH must ensure that healthcare services continue to be provided equitably and any risks associated with it are managed appropriately.

These are only a few of the systematic structures and processes within the Malaysian Healthcare System that have inherently funnel patients towards our already congested, understaffed and underfunded EDs. There are possibly many more (I don’t have the capacity to cover them all in this post). The bottom line is, it is crucial that we acknowledge that sometimes the problem lies not within our lack of resources to overcome it, but rather in having unknowingly created the problem in the first place. It is a bitter pill we have to swallow before we could make any progress towards the better.



(2) Chaiyachati K, Kangovi S Inappropriate ED visits: patient responsibility or an attribution bias?BMJ Quality & Safety Published Online First: 04 November 2019. doi: 10.1136/bmjqs-2019-009729

Image by sgrunden from Pixabay

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