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Presentation at workshop at the Asian Conference in Emergency Medicine at Busan Korea May 2009

Presentation at workshop at the Asian Conference in Emergency Medicine at Busan Korea May 2009

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  • 1. EMERGENCY MEDICAL SERVICES IN MALAYSIA Presenter: Dr Nik H A Rahman Emergency Physician Head of Dept Emergency Medicine School of Medical Sciences Universiti Sains Malaysia
  • 2. INTRODUCTION
  • 3.
    • 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
  • 4. 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
  • 5. INTRODUCTION
    • T otal number of doctors of 17 442
    • The ratio of doctors to population as in 2002 is 1 to 1 474
    • M OH 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
  • 6. INTRODUCTION Figures from Ministry of Health Malaysia 2007 Total admission = 1,905,689 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%
  • 7. Principal Causes of Deaths In Government Hospitals Malaysia in 2007 INTRODUCTION Figures from Ministry of Health Malaysia 2007 Total death = 49, 586 16.87% 15.70% 10.59% 8.49% 5.81% 5.59% 4.47% 4.20% 3.83% 3.03% Septicemia Heart Diseases & Diseases of Pulmonary Circulation Malignant Neoplasm Cerebrovascular Diseases Pneumonia Accident Diseases of Digestive System Perinatal Conditions Kidney Diseases Ill-Defined Conditions 1 2 3 4 5 6 7 8 9 10
  • 8. Motor Vehicle Crash & Type of Injuries Data from Royal Police Force Malaysia 2008 183,357 363,319 341,252 328,264 326,815 298,653 279,711 Total Case 170,357 336284 312564 289,136 280,546 254,499 237,378 Mechanical Damage 6,690 13979 15596 25,905 33,147 31,357 30,259 Mild Injuries 3,632 7384 7373 7,600 7,444 7,163 6,696 Serious Injuries 3,018 5672 5719 5,623 5,678 5,634 5,378 Death 2008 Jan-Jun 2007 2006 2005 2004 2003 2002 Motor vehicle Crash
  • 9. INTRODUCTION 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/ 216.1 216.1 220.6 237.4 233 232.7 234.6 236.3 224.7 230.9 Accident Index (10,000 registered vehicles) 3.7 3.98 4.18 4.52 4.9 4.9 5.17 5.69 5.83 6.28 Death Index (10,000 registered vehicles) 6,282 6,287 6,188 6,223 6,286 5,891 5,849 6,035 5,794 5,740 Total Death 7,384 7,375 7,600 7,444 7,163 6,696 8,684 9,790 10,383 12,068 Major injuries 13,979 15,596 25,928 33,413 37,415 35,236 35,973 34,375 36,886 37,885 Minor injuries 27,645 29,258 39,716 47,080 50,864 47,823 50,506 50,200 53,063 55,693 Total Injuries 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 Year
  • 10. 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
    • T he services was staffed by orthopedists, general
    • surgeons or generalists such as senior medical officers
    • U nderstaffed and patients are poorly managed
    • I t 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
  • 11.
    • Pre hospital & In Hospital EMS:
    • Infrastructure
    • Equipment upgrading
    • Staff training/allocation
    • Subspecialty areas
    • New ambulances
    • New Guidelines/protocol
    • Empowerment for EM physicians
    • Recognition (14 th 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…….
  • 12. 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
  • 13. 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)
  • 14. ORGANIZATION – Operating system Air & 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)
  • 15. STANDARDS i. Vehicles (staff & equipment) ii. Manpower (training/certification) iii. Response time (dispatch) iv. Call center v. Medical Control vi. Funding
  • 16. Vehicles (staff & equipment) Manned by non paramedics Ambulance driver with nursing staff Minimally trained & equipped Scoop & Run Concept Old Days !!!!
  • 17. Better equipped Trained nursing staff Accompanied by doc Vehicles (staff & equipment)
  • 18. 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 aid Civil Defense - basic life/trauma support/first aid/first responder Police – First responder program
  • 19. Manpower (training/certification)
    • Examples of effort by certain organization:
    • Hospital Universiti sains Malaysia
    • EMD program
    • Involve ambulance drivers and other support staff (BLS, BTLS, First aid)
    • ii. Civil Defense
    • iii. St Johns Ambulance
    • iv. UKM Medical Center
    • Ministry of Health
    • First responder for police force/armed forces
  • 20. 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) Mean Time in seconds ART = CPT + TTP + TTTS P=0.002 Ambulance Response Time (ART) 1646.21 1000 1609.39 911.50 1000 399.34 Time Taken To Arrive At Scene (TTTS) 1325.29 1000 1572.30 676.83 1000 1451.08 Time Taken to Prepare Team (TTP) 203.91 1000 115.24 117.00 1000 54.93 Call Processing Time (CPT) 117.00 1000 54.93 117.67 1000 55.20 GROUP Without EMD Mean Number of Calls Std Deviation With EMD Mean Number of Calls Std Deviation
  • 21. Mean Ambulance Response Time At Tertiary Hospitals In Three Different Cities in Malaysia Mean Time in seconds P<0.05 Response time (dispatch) 1539.78 1208.08 196.22 135.48 Kuala Lumpur 1268.96 896.33 218.56 154.07 Penang 911.50 676.83 117.00 117.67 Kota Bharu Mean Ambulance Response Time (ART) Mean Time Taken To Arrive At Scene (TTTS) Mean Time Taken to Prepare Team (TTP) Mean Call Processing Time (CPT) Cities
  • 22. i. 999 – Police ii. 994 – Fire & Rescue iii. 991 – Civil defence iv. 112 – Mobile phone services Malaysia Emergeny Response System OLD DAYS………………. Public got CONFUSED!!!!! Lack of Coordination!!!!! Miscommunication!!!!! Technical difficulties!!!!! Multitasking effort!!!!!
  • 23. Malaysia Emergeny Response System Major step……… June 2007
  • 24.
    • One number – “Client focus” (response to 999 calls within 10 sec or 4 rings)
    • “ Automatic routing system” with zero defect
    • Standardization of client interaction protocol for all call centers
    • Single “Communication network” for all agencies involved
    • “ Online incident management protocol” before arrival of response team
    • Trained EMD at call center
    Malaysia Emergeny Response System
  • 25. Malaysia Emergeny Response System Call center – Hospital based
  • 26. Ambulance call form Malaysia Emergeny Response System
  • 27. Ambulance calls 2008 – civil defense Technical fault (6.20%) Prank calls (8.07%) False calls (0.51%) True calls (82.6%)
  • 28. 1 – Motor vehicle crash 2 – Injury at workplace 3 – Commit suicide 4 - Assault 5 – Medical/surgical causes 6 – Trapped 7 – Submersion injury/drowning 8 – 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 10.21 2.29 3.09 0.08 0.24 45.61 1.19 0.47 0.63 36.19 Percentage 2,477 258 58 78 2 6 1,153 30 12 16 915 Total Cases
  • 29. January - Dicember 2008 35 3 3 1 0 1 2 5 11 6 3 Jumlah   1     1               Typhoon 9 0                     Aircrash 8 1             1       Landslide 7 0                     Industrial accident 6 8             1 3 2 2 SAR 5 0                     Maritime Incidence 4 2             1   1   Fire 3 0                     Collapse structure 2 23 3 3     1 2 2 8 3 1 Flooding 1 TOTAL OCTOBER SEPTEMBER AUGUST JULY JUNE MAY APRIL MARCH FEBRUARY JANUARY Mass Casualty Incidence №
  • 30. Pre Hospital Delivery of Care
    • Hospital ambulance based (MOH, University Hosp, Private Hosp.)
    • Receive calls at call center based in the emergency department
    • Dispatch ambulance to the site
    • Minimal intervention – scoop and run vs. stay and play
    • Bring the patient back to the base emergency dept
    • Facilities varies
    • Interfacility transport
    • From district hosp to tertiary centers or vice versa
    • Manned by nurses
    • Basic 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
  • 31. Stay & Play Concept Pre Hospital Delivery of Care
  • 32. In the past time……. Health Centers District hospital Tertiary Hospital Small ED Limited no of doctors Time ? Transportation problems Time ? No doctors Equipped ED Emergency Physicians OUTCOME POOR Acute hospital care Beyond the Golden / Platinum Hours : SURVIVAL POOR
  • 33. In the present time….. Health Center District hospital Tertiary Hospitals Doctors/MA present Transportation Time Communication Time REDUCED Emergency Medicine developing Better equipped ED Better transportation Acute hospital care
  • 34. Standard Resuscitation Bay in Emergency Dept
  • 35. Medical Control
    • Ambulance services in MOH/Univer Hosp are under the control of
    • Emergency Dept Headed by Emergency Physicians
    • Protocols and guidelines guided by EPs
    • Minimum One EP per state or per University Hosp
    • Training/Credentialling of ambulance staff is controlled by local dept.
    • Mostly Off line medical control, on line via walkie talkie/hand phone
    • Idea to privatise the service has been put forward – many obstacles!!
    • Private operators – No Emergency Physicians
    • Own protocol/guidelines
    • Medical direction off line/online
    • Credentialling ?????
    • Headed by senior staff members
  • 36. Funding
    • M OH 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
  • 37. RESEARCH Very limited Few 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.
  • 38. 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 Malaysia Khairi 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.
  • 39. PERFORMANCE INDICATOR
    • Ambulance response time
    • Call processing time
    • Crew mobilizing time
    • Client feedback/satisfaction
  • 40. Poor Excellent Vehicle appearance 1. General appearance of the ambulance 1 2 3 4 5 6 7 8 9 10 2. Cleanliness of ambulance 1 2 3 4 5 6 7 8 9 10 3. Comfort of ride in the ambulance 1 2 3 4 5 6 7 8 9 10 4. Feeling of security in the ambulance 1 2 3 4 5 6 7 8 9 10 5. 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 10 7. Attentiveness of staff 1 2 3 4 5 6 7 8 9 10 8. Empathy nature of staff 1 2 3 4 5 6 7 8 9 10 9. Friendliness of staff 1 2 3 4 5 6 7 8 9 10 10. 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 10 12. Calmness of staffs 1 2 3 4 5 6 7 8 9 10 13. Adequacy of explanation by staff of their actions 1 2 3 4 5 6 7 8 9 10 14. Efficiency of staff 1 2 3 4 5 6 7 8 9 10 15. 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 10 17. Professional look of staff 1 2 3 4 5 6 7 8 9 10 18. Level of trust in staff 1 2 3 4 5 6 7 8 9 10 19. Level of competency of staff 1 2 3 4 5 6 7 8 9 10 20. 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 10 22. Response time of ambulance to an emergency 1 2 3 4 5 6 7 8 9 10 23. 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
  • 41. PRESENT & FUTURE CHALLENGES
    • Multiple providers
    • Non standard training program/certification
    • Poorly or untrained EMS staff
    • Poor public comprehension about EMS
    • Non uniformity of allocation in services
    • Poorly equipped ambulances
    • Poor quality ambulances
    • Lack of EMS research and quality control
    • Privatizing the service ???
  • 42.