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 ???