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Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues
 

Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues

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This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus ...

This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus mainly on prehospital and A&E setting. Issues that are conventionally under the care of the cardiologists are not discussed.

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    Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues Presentation Transcript

    • Handling  Cardiovascular  Emergencies  In  A   Malaysian  Hospital   (A  Personal  Reflec/on  on  Issues  and  Challenges  Ahead) K  S  Chew   Senior  Lecturer/Emergency  Physician,   Emergency  Medicine  Department   UniversiC  Sains  Malaysia   16150  Kubang  Kerian,  Kelantan,  Malaysia  
    • Disclaimer:   The  views  presented  here  are  of  my  own  personal  reflec/on   and  is  not  represen/ng  any  official  statement/opinion  from   the  Ministry  of  Heath  Malaysia  
    • Malaysia   mulC-­‐ethnic,  mulC-­‐religion  country  consisCng  of  13  states  and   three  federal  territories.  Majority  of  the  Malaysian  populaCon  of   about  27  million  people  consists  of  the  Malays  (50.4%),  Chinese   (23.7%),  the  indigenous  groups  (11%)  and  the  Indians  (7.1%)  
    • MALAYSIA HEALTH FACTS 2006 2007 2008 Life Expectancy: Male 71.8 years 71.7 years 71.7 years Life Expectancy: Female 76.3 years 76.5 years 76.5 years No of MOH Hospitals 128 (30,969) 130 (32,149) 130 (33,004) (no of beds) No of Private Hospitals NA 195 (11,291) 209 (11,689) (no of beds) No of MOH Clinics 807 806 802 No of MOH Community Clinics 1,919 1,927 1,927 Total no of Public Doctors 13,335 14,298 15,096 Total no of Private Doctors 8,602 9,440 10,006 Doctor : Population Ratio 1:1,214 1 : 1,145 1 : 1,105 Reference:  Health  Facts  2006,  2007  and  2008.  Ministry  of  Health,  Malaysia  Official  Website.  URL:  www.moh.gov.my  
    • Top  Ten  Causes  of  HospitalizaCon  in  Malaysian   Ministry  of  Health  Hospitals  2008 1   Normal  Deliveries   13.99%   2   ComplicaCons  of  Pregnancy,  Childbirth  and  the   12.77%   Puerperium   3   Accidents   8.40%   4   Diseases  of  the  Respiratory  System   8.05%   5   Diseases  of  the  Circulatory  System   6.99%   6   CondiCons  OriginaCng  in  the  Perinatal  Period   6.78%   7   Diseases  of  the  DigesCve  System   5.37%   8   Ill-­‐defined  CondiCons   3.63%   9   Diseases  of  the  Urinary  System   3.49%   10   Malignant  Neoplasms   3.16%   Reference:  Health  Facts  2008.  Ministry  of  Health,  Malaysia  Official  Website.  URL:  www.moh.gov.my  
    • Top  Ten  Causes  of  Deaths  in  Malaysian  Ministry   of  Health  Hospitals  2008 1   Heart  and  Pulmonary  CirculaCon  Diseases   16.54%   2   SepCcaemia   13.18%   3   Malignant  Neoplasms   11.21%   4   Pneumonia   9.28%   5   Cerebrovascular  Diseases   8.65%   6   Diseases  of  the  DigesCve  System   5.18%   7   Accidents   5.00%   8   CondiCons  OriginaCng  in  the  Perinatal  Period   3.97%   9   NephriCs,  NephroCc  Syndrome  and  Nephrosis   3.76%   10   Ill-­‐  defined  CondiCons    2.63%   Reference:  Health  Facts  2008.  Ministry  of  Health,  Malaysia  Official  Website.  URL:  www.moh.gov.my  
    • Flow  Chart  of  The  Emergency  Management  of  Acute   Coronary  Syndrome   For PCI Inter-facility transfer Chest pain Call 999 EMS Response Triage Plan Fibrinolysis Patient’s Dispatch EMS EMS Transport Door to Needle time: 30 min symptoms Arrival 1 min 12-lead ECG Door to Balloon time: 90 min within 8 5 min after min ? Pre-hospital thrombolysis Inter-facility transfer onset Advice S/L GTN q5min, max 3 tablets Cardiopulmonary Resuscitation Automated External Defibrillator
    • Reference:  Clinical  Prac/ce   Guidelines  Management  of   Acute  ST  Eleva/on  Myocardial   Infarc/on  2007.  Ministry  of   Health  Malaysia.   www.moh.gov.my  
    • Issues  Related  To  EMS  AcCvaCon  
    • PREVIOUS  EMERGENCY  AMBULANCE  CALL  SYSTEM   PRIOR  TO  2007     (LACK  OF  AN  INTEGRATED  RESPONSE  SYSTEM)   EMERGENCY  CALL   999   HOSPITAL   HEALTH  CLINIC   991   PHONE  NUMBER     PHONE  NUMBER   TELEKOM     OPERATOR   HOSPITAL   JPA  3   OPERATOR   HEALTH  CLINIC   PARAMEDIC   EMERGENCY   JPA  3  TEAM   DEPARTMENT  
    • • SCll  plagued  with  the  problem  of  prank   calls.   • In  2007,  97%  of  the  2  million  emergency   calls  are  prank  calls.   • In  2008,  the  percentage  was  64%.   • Prank  callers  can  be  charged  under   SecCon  223  of  the  Malaysian   CommunicaCons  and  MulCmedia  Act   Chew  KS,  Idzwan  ZM,  Hisamuddin  NA,  Kamaruddin  J,  Wan   1998,  which  carries  a  fine  of  up  to   Aasim  WA.  Cardiopulmonary  Resuscita/on:  The  Short   RM50,000  or  up  to  five  years  jail  or  both.   Comings  In  Malaysia.  Malaysian  J  Med  Sciences.  2008;14(2): 23-­‐5.  
    • Issues  Related  To  EMS  Response  
    • Ambulance  Response  Time   Cities Mean Ambulance Response Time (min) Kota Bharu 15.2 Kuala Lumpur 21.1 United Kingdom 7.0 – 14.0 Australia 7.0 – 11.0 Singapore ± 15.0 Ankara (Turkey) ±9 New York ± 11.4 Chicago ± 11.3 Shah  CH,  Ismail  IM,  Mohsin  SS.  Ambulance  response  /me  and  emergency  medical  dispatcher  program:  a  study  in  Kelantan,   Malaysia.  Southeast  Asian  J  Trop  Med  Public  Health  2008;  39  (6):1150-­‐4.   Chew  KS,  Idzwan  ZM,  Hisamuddin  NA,  Kamaruddin  J,  Wan  Aasim  WA.  Cardiopulmonary  Resuscita/on:  The  Short  Comings  In   Malaysia.  Malaysian  J  Med  Sciences.  2008;14(2):23-­‐5.  
    • Bicycle  and  Motorcycle  Squad  Around   Klang  Valley  Vicinity  As  A  Stop-­‐Gap   Measure   Motorcycle  Squad   • Area  covers  100  –150  km  sq   • ‘Response  Time’  less  than  15  min   • Distance  less  than  10km  or  travel  Cme   less  15  min   • The  Advanced  Life  Support  Unit  type   complete  equipments  including:  AED,   Airway  Management  Set,  MedicaCons,   Oxygen  Tank,  CommunicaCon  Set  
    • “One  Size  Fit  All”  in  FormulaCng   An    Emergency  Medical  Service   System  In  Malaysia???  
    • Klinik  Desa  Bario  -­‐  Sarawak  
    • KK  Pa  Dalih  –  Up  To  Ten  Hours’   Journey  On  Foot  
    • Issues  Related  To  ResuscitaCon  
    • Cardiopulmonary  ResuscitaCon   •  Bystander  CPR  is  performed  in  9%  of  out  of  hospital   cardiac  arrest  in  a  local  study  in  2006.   •  Chew  KS,  Mohd  Idzwan  Z,  Nik  Hishamudin  NA,  Wan   Aasim  WA,  Kamaruddin  J.  How  frequent  is  bystander   cardiopulmonary  resuscita/on  performed  in  the   community  of  Kota  Bharu,  Malaysia?  Singapore  Med  J.   2008  Aug;49(8):636-­‐9.  
    • Willingness  of  Final  Year  Medical  and  Dental   Students  To  Perform  Bystander  CPR   Chew  KS,  Yazid  MNA.  The  willingness  of  final  year  medical  and  dental  students  to  perform   bystander  cardiopulmonary  resuscita/on  in  an  Asian  community  Int  J  Emerg  Med.  2008;1(4): 301-­‐09.  
    • Willingness  of  Final  Year  Medical  and  Dental   Students  To  Perform  Bystander  CPR   Chew  KS,  Yazid  MNA.  The  willingness  of  final  year  medical  and  dental  students  to  perform   bystander  cardiopulmonary  resuscita/on  in  an  Asian  community  Int  J  Emerg  Med.  2008;1(4): 301-­‐09.  
    • Unspoken  socio-­‐cultural   barriers  to  perform  bystander   CPR  with  mouth-­‐to-­‐mouth   venClaCon  among  our  mulC-­‐ ethnic,  mulC-­‐religious   community   Gender  difference  is  probably  one  of  these,  especially  among  the   female  respondents  (performing  bystander  CPR  on  a  male  vicCm)   Chew  KS,  Yazid  MNA.  The  willingness  of  final  year  medical  and  dental  students  to  perform  bystander   cardiopulmonary  resuscita/on  in  an  Asian  community  Int  J  Emerg  Med.  2008;1(4):301-­‐09.  
    • Issues  Related  To  Automated   External  Defibrillator  in  Malaysia
    • Issues  Related  To  DefiniCve   Coronary  Care  Plan  
    • Malaysian  NaConal  Cardiovascular  Disease   (NCVD)  Database   •  In  2006,  there  are  73  coronary  care  units  (CCU)  in   Malaysia   •  The  incidence  of  ACS  admission  was  therefore  47.1   per  100,000  populaCon  in  2006   •  The  esCmate  of  the  incidence  of  coronary  heart   disease  (CHD)  in  Malaysia  is  141  per  100,000   populaCon   •  Over  4000  ACS  being  denied  admission  into  its  CCU   in  2006.  It  has  30%  shoroall  in  CCU  beds   Chin SP, Jeyaindran S, Azhari R, Wan Azman WA, Omar I, Robaayah Z, Sim KH. Acute coronary syndrome (ACS) registry--leading the charge for National Cardiovascular Disease (NCVD) Database. Med J Malaysia. 2008 Sep;63 Suppl C:29-36.
    • Overall  Outcomes  For  PaCents  With  STEMI  By   FibrinolyCc  Therapy,  Malaysia  2006   In-­‐hospital   30-­‐day*   Outcome   Fibrinoly=c  therapy   Fibrinoly=c  therapy   Yes   No   Yes   No   No.   %   No.   %   No.   %   No.   %   Discharged  /   Alive   940   92   372   87   686   67   253   59   Died   74   7   55   13   90   9   68   16   Lost  to     follow-­‐up   NA   NA   NA   NA   242   24   106   25   Missing   4   0   0   0   0   0   0   0   *Including  pa/ents  who  died  in-­‐hospital.   Note:  Percentage  is  to  the  nearest  decimal  point.   Annual  Report  of  the  Acute  Coronary  Syndrome  (ACS)  Registry,  Malaysia  2006  
    • Streptokinase  Failure   •  In  a  local  study  in  2008,  streptokinase  failure  rate  is   56.8%   •  Mean  door-­‐to-­‐needle  Cme  is  104.9  min   •  Other  factors  shown  to  significantly  associated  with   streptokinase  failure  include   –  Anterior  locaCon  infarcCon   –  History  of  Diabetes   –  Hypertension   –  High  total  white  cell  counts   –  Lee  YY,  Tee  MH,  Zurkurnai  Y  et  al.  Thromboly/c  failure  with   streptokinase  in  acute  myocardial  infarc/on  using  electrocardiogram   criteria.  Singapore  Med  J  2008;  49  (4):304-­‐10.   Note:  Streptokinase  failure  in  this  study  is  based  solely  on  ECG  criteria  of  failure  of  STE  of  ≥  50%  and  not  on  angiographic   confirma=on  
    • NCVD-­‐PCI  Registry  Results   PCI  Status   Baseline  (n=8,236)   ElecCve  (n=7,439)   90.32  %                      Staged  PCI   22.06  %   Urgent  (NSTEMI/UA)   4.66  %   Rescue   2.09  %   Primary   2.48  %   Missing   0.45  %   Cath/  PCI  in  same  seqng  (ad  hoc)   84.12  %   Na=onal  Cardiovascular  Disease  Database  (NCVD)  
    • Percentage  Of  Stent  Type  By  Total  Number  Of   Stents  Used  (N=13,150)   *‘Other’  refers  to  stent  other  than  listed  in  the  Reference  Stent  List   Na=onal  Cardiovascular  Disease  Database  (NCVD)  
    • Conclusion  
    • Thank  You