CNA Explains: Why the nearest hospital isn't always the best choice in an emergency

SINGAPORE: After a Singapore Sports School student died in October, questions were raised on why the 14-year-old was sent to National University Hospital (NUH) when Khoo Teck Puat Hospital was nearer. 

The Singapore Civil Defence Force (SCDF), which operates a 24-hour response to medical emergencies in Singapore, said the decision was in line with medical protocol.

Has this protocol been questioned before?

Yes. And the SCDF has had to reiterate its policies from time to time, especially in the wake of high-profile incidents.

In the case of a 2019 Lucky Plaza car crash, victims were sent to Tan Tock Seng Hospital (TTSH) in Novena rather than Mount Elizabeth Hospital, which was about 200m from the accident scene.

The Ministry of Health (MOH) and SCDF said Mount Elizabeth Hospital was not equipped for the situation. 

Another accident involving a speeding Ferrari in 2012 also sparked debate when victims were brought to Singapore General Hospital (SGH) and TTSH – instead of privately-run Raffles Hospital, which was close by.

Then, a group of emergency medical specialists spoke up in defence of SCDF, saying public hospitals were better equipped and staffed to handle the victims.

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How is it decided which hospital to send patients to? 

SCDF’s policy is to send patients to the nearest MOH-designated hospitals to be treated quickly.

“The fastest arrival of patients at the nearest hospital with the appropriate medical facility can make all the difference between life and death in an emergency,” SCDF said on its website.

The emergency service also takes into account prevailing traffic conditions, and its operation centre provides the fastest travel time to an appropriate MOH-designated hospital. 

Emergency medicine specialist Sanjeev Shanker said that where the patient is sent depends on the nature and severity of the case. 

Those in cardiac arrest or experiencing a heart attack or stroke will need emergency treatment with as little delay as possible, said the doctor from StarMed Specialist Centre.

Adjunct Assistant Professor Teo Li-Tserng, a senior consultant and director of the trauma centre at TTSH, said that all public hospitals are equipped to perform immediate lifesaving.

But there are more dedicated resources and workflows in certain hospitals, to manage more complex cases.

“The concept should always be based on the maxim of right hospital, right patient and right specialty,” he added. 

What do some hospitals specialise in? 

Dr Shanker said children in stable condition will be taken to either KKH or NUH – hospitals with dedicated paediatric A&E departments and wards.

Similarly, obstetric patients who are stable will be sent directly to KKH, NUH or SGH where there are obstetricians on call within the hospital at all times and a delivery ward should the need arise, said the doctor. 

SCDF has said that patients with smoke inhalation or serious burn injuries will be brought to the specialised Burn Centre at the Singapore General Hospital. But if their condition is too unstable, they will be taken to the nearest MOH-designated hospital.

Severe trauma or acute stroke cases, meanwhile, will be sent to specific MOH-designated hospitals with the necessary facilities and expertise.

TTSH is the designated anchor hospital for central Singapore, said Dr Teo.

The hospital has dedicated trauma-trained personnel forming the largest team in Singapore, including on-call surgeons. 

Dr Teo also noted that TTSH’s trauma rehabilitation physicians can start rehab early with an acutely injured patient. The goal would be to minimise the chances of the patient suffering from their medical conditions in the longer term. 

CNA reached out to other hospitals, experts and professional organisations on the emergency specialisations in Singapore’s hospital network, among other questions. They declined to comment.

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Are patients disadvantaged when sent to hospitals further away? 

Dr Teo said that in Singapore, the distances involved in transporting patients to a hospital have not proven to be a drawback.

In any case, the perception that longer travel time puts a patient at a disadvantage is wrong, the doctor added. 

“The time ‘saved’ to go to the nearest but not most appropriate hospital will cause more delays and a poorer outcome,” he said.

Dr Teo gave the example of a trauma patient being sent to a hospital not suited to manage his condition, and which ends up arranging for him to be transferred.

The subsequent process of stabilising, activating an ambulance, calling the receiving hospital and other factors will need about one hour to organise.

This would exceed any travel time “savings”, and during that hour, the patient still has not received appropriate attention, said Dr Teo.

Can patients be taken to a nearer private hospital? 

No, unless it’s Raffles Hospital.

Patients picked up by an SCDF ambulance may be sent to the emergency department there, if they are assessed to be in non-life threatening conditions and if Raffles Hospital is the nearest available and appropriate facility.

They can only be sent during office hours, excluding weekends and public holidays.

Patients with certain conditions such as obstetric or paediatric-related, major trauma and mental health ones will not be sent there. Neither will those with communicable diseases, severe burns or injuries related to hazardous materials.

In 2020, then-senior Minister of State for Health Edwin Tong said in parliament that private hospitals were not configured to provide the full range of emergency and trauma services needed to manage all life-threatening situations.