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Presenter:
Dr Nik H A RahmanEmergency Physician
Head of Dept Emergency MedicineSchool of Medical SciencesUniversiti Sains Malaysia
INTRODUCTION
Malaysia is located in South East Asia
Bordered by Thailand in the north and Singapore in the south
Consists of 15 states and has a democratic government
Comprises of multi-ethnic groups, the Malay group being the majority (70%) and others such as Chinese and Indians
The land area is 330,252 square kilometers with a population of just over 25 million
INTRODUCTION
INTRODUCTION
Life expectancy at birth in 2008 for males was 70.3 years and for females, 75.2 years
The health facilities are provided by the Ministry of Health (MOH), Ministry of Education (university hospitals), and private sectors
Each of the 15 states are provided with a General Hospital that perform as referral center
INTRODUCTION
Total number of doctors of 17 442
The ratio of doctors to population as in 2002 is 1 to 1 474
MOH allocation to National Budget is 6.33%, amounting to Malaysian Ringgit (RM) 5 765 553 410
80% of which was for the operating budget and the other 20% for the development budget
INTRODUCTION
1 Normal Delivery 14.91%
2 Complications of Pregnancy 12.39%
3 Accident 9.11%
4 Diseases of the Respiratory Systems 7.30%
5 Diseases of the Circulatory Systems 7.26%
6 Perinatal Conditions 6.57%
7 Diseases of the Digestive Systems 5.20%
8 Diseases of the Urinary Systems 3.74%
9 Ill-defined Conditions Diseases 3.43%
10 Malignant Neoplasms 3.13%
Figures from Ministry of Health Malaysia 2007
Total admission = 1,905,689
Principal Causes of Deaths In Government Hospitals Malaysia in 2007
1
2
3
4
5
6
7
8
9
10
Septicemia
Heart Diseases & Diseases of Pulmonary Circulation
Malignant Neoplasm
Cerebrovascular Diseases
Pneumonia
Accident
Diseases of Digestive System
Perinatal Conditions
Kidney Diseases
Ill-Defined Conditions
16.87%
15.70%
10.59%
8.49%
5.81%
5.59%
4.47%
4.20%
3.83%
3.03%
INTRODUCTION
Figures from Ministry of Health Malaysia 2007
Total death = 49, 586
Motor vehicle Crash
2002 2003 2004 2005 2006 20072008
Jan-Jun
Death 5,378 5,634 5,678 5,623 5719 5672 3,018
Serious Injuries
6,696 7,163 7,444 7,600 7373 7384 3,632
Mild Injuries 30,259 31,357 33,147 25,905 15596 13979 6,690
Mechanical Damage
237,378 254,499280,54
6289,136 312564 336284 170,357
Total Case 279,71
1298,65
3326,81
5328,26
4341,25
2363,319 183,357
Motor Vehicle Crash & Type of Injuries
Data from Royal Police Force Malaysia 2008
INTRODUCTION
Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Total Injuries 55,693 53,06350,200
50,506
47,823
50,864 47,08039,716
29,25827,645
Minor injuries 37,885 36,88634,375
35,973
35,236
37,415 33,41325,928
15,59613,979
Major injuries 12,068 10,383 9,790 8,684 6,696 7,163 7,444 7,600 7,375 7,384
Total Death 5,740 5,794 6,035 5,849 5,891 6,286 6,223 6,188 6,287 6,282
Death Index(10,000 registered vehicles)
6.28 5.83 5.69 5.17 4.9 4.9 4.52 4.18 3.98 3.7
Accident Index(10,000 registered vehicles)
230.9 224.7 236.3 234.6 232.7 233 237.4 220.6 216.1 216.1
Major injuries & Total injuries REDUCING TREND BUT…..
TOTAL DEATH UNCHANGED !!!!
10 year statistic on Road Traffic Accident
(Data from: safety & road dept. Malaysia 2009)
http://www.jkjr.gov.my/
Historically Historically EMS in Malaysia was very underdeveloped prior
to 1998
It was the most neglected clinical part of the hospital & health system for many years
The services was staffed by orthopedists, general surgeons or generalists such as senior medical officers
Understaffed and patients are poorly managed
It was a place for dumping those medical staff with attitude problems or without career planning
Fortunately the health administrators and public are gradually changing this bad perception
Certain facilities and services are becoming better since the presence of the fully qualified Emergency Physicians
Pre hospital & In Hospital EMS:
Infrastructure
Equipment upgrading
Staff training/allocation
Subspecialty areas
New ambulances
New Guidelines/protocol
Empowerment for EM physicians
Recognition (14th specialty)
Training:
More universities for EM postgraduate program
- Conjoint program/exam board
Now total EPs are 55 (Min 1 EP per state)
Paramedic training increased
Public training/education – life support
At Present…….
ORGANIZATION – Operating system
In general prehospital care is still underdeveloped
Emergency medicine has just passed the infancy phase
Anglo American model
Government & NGO’s service provision by:
- Hospital/Health- Civil Defence- Fire & rescue services
- St John’s Association- Malaysia Red Crscent- Private Health sectors
ORGANIZATION – Operating system
Land ambulances
- Government (MOH, University Hospitals, Civil Defense)
- NGOs (St John’s, Red Crescent, Private organization)
- Hospital based (General Hospital, University Hospitals, District)
- Hospital receives ambulance call
- Also utilized for inter facility transfers (district to tertiary centers)
ORGANIZATION – Operating systemAir & water ambulances
- For rural areas (East Malaysia, borneo)
- Austere environment
- Mainly governmental services
RM 5.1 Million (USD 1.4 Million for operating flying doctors)
STANDARDS
i. Vehicles (staff & equipment)
ii. Manpower (training/certification)
iii. Response time (dispatch)
iv. Call center
v. Medical Control
vi. Funding
Vehicles (staff & equipment)
Manned by non paramedicsAmbulance driver with nursing staffMinimally trained & equipped
Scoop & Run Concept
Old Days !!!!
Better equippedTrained nursing staffAccompanied by doc
Vehicles (staff & equipment)
Manpower (training/certification)
Level of care:
- Depends on the operators i.e MOH or private sectors- Manned by ambulance driver – basic paramedic/murses - doctors- Levels of training varies and not standardized certification program- No legislation formatted- Care level ranges from first aid – first responder – basic life support- Occasionally doctors accompanying seriously ill patients- No EMT program- Recently variety of organization have implemented training program
Nurses/Medical Assistants – basic life/trauma support/first aidCivil Defense - basic life/trauma support/first aid/first responderPolice – First responder program
Manpower (training/certification)
Examples of effort by certain organization:
i. Hospital Universiti sains Malaysia
EMD programInvolve ambulance drivers and other support staff (BLS, BTLS, First aid)
ii. Civil Defense
iii. St Johns Ambulance
iv. UKM Medical Center
v. Ministry of Health
First responder for police force/armed forces
Response time (dispatch)
Ambulance Response Time (ART) Before and After Emergency Medical Dispatcher (EMD) Training Program (Statistics January Till December 2004 from Call Center Hospital Universiti Sains Malaysia)
GROUP
Without EMDMeanNumber of CallsStd Deviation
With EMDMeanNumber of CallsStd Deviation
Call Processing Time (CPT)
117.00100054.93
117.67100055.20
Time Taken to Prepare Team
(TTP)
203.911000
115.24
117.00100054.93
Time Taken To Arrive At Scene (TTTS)
1325.291000
1572.30
676.831000
1451.08
Ambulance Response Time (ART)
1646.2110001609.39
911.501000399.34
Mean Time in secondsART = CPT + TTP + TTTS
P=0.002
Mean Ambulance Response Time At Tertiary Hospitals In Three Different Cities in Malaysia
Cities Mean Call Processing Time (CPT)
Mean Time Taken to Prepare Team(TTP)
Mean Time Taken To Arrive At
Scene (TTTS)
Mean Ambulance Response
Time (ART)
Kota Bharu 117.67 117.00 676.83 911.50
Penang 154.07 218.56 896.33 1268.96
Kuala Lumpur
135.48 196.22 1208.08 1539.78
Mean Time in seconds P<0.05
Response time (dispatch)
i. 999 – Policeii. 994 – Fire & Rescueiii. 991 – Civil defenceiv. 112 – Mobile phone services
Malaysia Emergeny Response System
OLD DAYS……………….
Public got CONFUSED!!!!!Lack of Coordination!!!!!Miscommunication!!!!!Technical difficulties!!!!!Multitasking effort!!!!!
Malaysia Emergeny Response System
Major step………June 2007
i. One number – “Client focus” (response to 999 calls within 10 sec or 4 rings)
ii. “Automatic routing system” with zero defect
iii. Standardization of client interaction protocol for all call centers
iv. Single “Communication network” for all agencies involved
v. “Online incident management protocol” before arrival of response team
vi. Trained EMD at call center
Malaysia Emergeny Response System
Malaysia Emergeny Response System
Call center – Hospital based
Ambulance call form
Malaysia Emergeny Response System
Ambulance calls 2008 – civil defense
Technical fault (6.20%)
Prank calls (8.07%)
False calls (0.51%)
True calls (82.6%)
Total Cases 915 16 12 30 1,153 6 2 78 58 258 2,477
Percentage 36.19
0.630.47
1.19
45.61 0.24 0.083.09
2.29
10.21
1 – Motor vehicle crash2 – Injury at workplace3 – Commit suicide4 - Assault
5 – Medical/surgical causes6 – Trapped7 – Submersion injury/drowning8 – Wild reptile (snakes)
9 – Bee/Hornet 10 - Others
1 2 3 4 5 6 7 8 9 10 Total
Malaysia Emergeny Response System
- Civil Defense 2008 Statistic
0
2
4
6
8
10
12
14
Perlis
Kedah
P.Pina
ng
Perak
Selang
or
WP K
L
N.Sem
bilan
Mela
kaJo
hor
Pahan
g
Teren
ggan
u
Kelant
an
Sabah
Saraw
ak
Disember
November
Oktober
September
Ogos
Julai
Jun
Mei
April
Mac
Februari
Januari№
MassCasualtyIncidence
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TOTAL
1 Flooding 1 3 8 2 2 1 3 3 23
2 Collapse structure 0
3 Fire 1 1 2
4 Maritime Incidence 0
5 SAR 2 2 3 1 8
6 Industrial accident 0
7 Landslide 1 1
8 Aircrash 0
9 Typhoon 1 1
Jumlah 3 6 11 5 2 1 0 1 3 3 35
January - Dicember 2008
Pre Hospital Delivery of Carei. Hospital ambulance based (MOH, University Hosp, Private Hosp.)
Receive calls at call center based in the emergency departmentDispatch ambulance to the siteMinimal intervention – scoop and run vs. stay and playBring the patient back to the base emergency deptFacilities varies
Interfacility transportFrom district hosp to tertiary centers or vice versaManned by nursesBasic facilities
ii. Private Operator (St John’s, Red Crescent)
Receive call at their own call center out of hospital Dispatch ambulance Staff minimally trained – BLS/First aid
Bring patient to nearest health facility Lack of Coordination with government operators
Stay & Play Concept
Pre Hospital Delivery of Care
In the past time…….
Health Centers District hospital
Tertiary Hospital
Small EDLimited no ofdoctors
Time ?Transportation problems
Time ?
No doctors
Equipped EDEmergencyPhysicians
OUTCOMEPOOR
Acute hospital care
Beyond the Golden / Platinum Hours : SURVIVAL POOR
In the present time…..
Health Center
District hospital
Tertiary Hospitals
Doctors/MA present
Transportation TimeCommunication Time
REDUCED
Emergency Medicine developingBetter equipped EDBetter transportation
Acute hospital care
Standard Resuscitation Bay in Emergency Dept
Medical Control
i. Ambulance services in MOH/Univer Hosp are under the control of Emergency Dept Headed by Emergency Physiciansii. Protocols and guidelines guided by EPsiii. Minimum One EP per state or per University Hospiii. Training/Credentialling of ambulance staff is controlled by local dept.iv. Mostly Off line medical control, on line via walkie talkie/hand phonev. Idea to privatise the service has been put forward – many obstacles!!
i. Private operators – No Emergency Physiciansii. Own protocol/guidelinesiii. Medical direction off line/onlineiv. Credentialling ?????v. Headed by senior staff members
Funding
MOH allocation to National Budget is 6.33%, amounting to Malaysian Ringgit (RM) 5 765 553 410 Government Hospitals – allocation of budget to the Emergency dept Budget for vehicles come from state health office Equipment budget from the dept. Priority for Emergency services is less More focus on
RESEARCH
Very limitedFew research conducted by Trainee in Emergency Medicine
“A study on the ambulance call received at the call center Hospital Universiti Sains Malaysia”
Zainalabidin I, Nik Hisamuddin NAR, Rashidi A, Mohd Shaharuddin S. May 2007
High percentage of misuse (mostly prank calls) of the emergency hotline. Half of the ambulance
Calls were associated woth communication difficulties
“Pattern of injury & preventability of prehospital death among motorcyclist”Noor Azleen A, Wan Aasim WA, Rashidi A, Nik Hisamuddin NAR. May 2006
Based on ISS, 67% had ISS > 50, 31% had ISS of 75. 36% of them died before reaching
Hospitals. 39% died in the Emerg dept.
RESEARCH
“Interhospital ambulance transportation of critically patients to Kuala Lumpur Hospital”Ridzuan MI, Abu Hassan A, Wan Aasim WA, Kamaruddin J, Rashidi A, Nik Hisamuddin NAR. May 2003
58% were trauma cases, 68% referral from district hospitals & health centers. 51% seriouslyill patient were accompanied by junior doctors only trained at the level of BLS. 47% of ambulance equipped with two way radio communications
Ambulance call response interval in Kuala Lumpur MalaysiaKhairi K, Abu Hassan A, Kamaruddin J, Wan Aasim WA. May 2003
The ambulance call response interval was 15.1 + 8.4 minutes. The causes of delay include traffic jam, wrong address, wrong route taken, tall building.
PERFORMANCE INDICATOR
i. Ambulance response timeii. Call processing timeiii. Crew mobilizing timeiv. Client feedback/satisfaction
Poor Excellent
Vehicle appearance 1. General appearance of the ambulance 1 2 3 4 5 6 7 8 9 102. Cleanliness of ambulance 1 2 3 4 5 6 7 8 9 103. Comfort of ride in the ambulance 1 2 3 4 5 6 7 8 9 104. Feeling of security in the ambulance 1 2 3 4 5 6 7 8 9 105. Adequacy of ambulance equipments 1 2 3 4 5 6 7 8 9 10
Staff attitude 6. Helpfulness of staff 1 2 3 4 5 6 7 8 9 107. Attentiveness of staff 1 2 3 4 5 6 7 8 9 108. Empathy nature of staff 1 2 3 4 5 6 7 8 9 109. Friendliness of staff 1 2 3 4 5 6 7 8 9 1010. Gentleness of staff 1 2 3 4 5 6 7 8 9 10
Staff performance 11. Ensuring of patient’s comfort 1 2 3 4 5 6 7 8 9 1012. Calmness of staffs 1 2 3 4 5 6 7 8 9 1013. Adequacy of explanation by staff of their actions 1 2 3 4 5 6 7 8 9 1014. Efficiency of staff 1 2 3 4 5 6 7 8 9 1015. Feeling of safety when staff arrive 1 2 3 4 5 6 7 8 9 10
Professionalism 16. Perceived level of training of staff 1 2 3 4 5 6 7 8 9 1017. Professional look of staff 1 2 3 4 5 6 7 8 9 1018. Level of trust in staff 1 2 3 4 5 6 7 8 9 1019. Level of competency of staff 1 2 3 4 5 6 7 8 9 1020. Confidence of staff to keep me alive until reaching hospital 1 2 3 4 5 6 7 8 9 10
Efficiency of service 21. Availability of staff at all times 1 2 3 4 5 6 7 8 9 1022. Response time of ambulance to an emergency 1 2 3 4 5 6 7 8 9 1023. Speed of admittance to hospital 1 2 3 4 5 6 7 8 9 10
Image 24. What do you think is the public perception of our ambulance service? 1 2 3 4 5 6 7 8 9 10
PRESENT & FUTURE CHALLENGES
i. Multiple providersii. Non standard training program/certificationiii.Poorly or untrained EMS staffiv.Poor public comprehension about EMSv. Non uniformity of allocation in servicesvi.Poorly equipped ambulancesvii.Poor quality ambulancesviii.Lack of EMS research and quality controlix.Privatizing the service ???