Trauma System in Malaysia: An experience in University Malaya Medical Centre

1. Trauma System in Malaysia: An experience in University Malaya Medical Centre Assoc Prof Dr MohdIdzwan bin Zakaria Consultant Emergency Physician UMMC President College of Emergency Physicians Academy of Medicine Malaysia

2. Effective trauma system Effective prehospital care providers and protocols Designated trauma centres Trained trauma specialists and paramedic Rehab facilities Communication and coordination Trauma registry J. Duranteau :Trauma System in Europe http://www.darbicetre.com/traumatologie/pdfcours/2011 _JDuranteau_24_Trauma_systems_in%20Europe.pdf Research programme

3. University Malaya Medical Centre (UMMC) • Tertiary referral centre • Oldest university hospital in Malaysia • Government funded public hospital • Approximately 1700 nurses and paramedics and 800 doctors • Annual patients’ attendance: 100,000/year • Catchment area for pre hospital care: 25km radius

4. Highly congested area • Population density: 3,700/km2

5. Come on Malaysians!! Let me pass

6. UMMC

7. UMMC

8. Objectives

9. Clinical risk management Decision making by Junior MO Late referral Poor communication Poor prioritization Late decision making

10. Patient safety

11. Redistribution of trauma care roles • Resuscitative and critical care phases • Emergency physicians • ATLS or MTLS trained • Expert in trauma resuscitation and core procedures • Privileging process and credentialed • Currently at least 2-3 EPs in a hospital with specialists • Able to direct trauma team before definitive treatment by surgeons (high-risk patients) Emergency physician As team leader Before arrival of surgeon Steven M. Green, Trauma Is Occasionally a Surgical Disease: How Can We Best Predict When?; Annals of Emerg Med. 2011; 58(2): 172-177

12. Surgeon then act as team leader once arrived • It is of course critical that skilled surgeons be quickly available because injured patients will occasionally die without rapid operative intervention. Steven M. Green, Trauma Is Occasionally a Surgical Disease: How Can We Best Predict When?; Annals of Emerg Med. 2011; 58(2): 172-177 This is our issue in ED initially

13. Study on outcome • 1st January until 31st July 2011 (trauma team activated group: TTA) • 7 months • Compared with 9th May 2010 until 19th December 2010 (trauma team non activated: TTNA) • Samples with ISS > 15 • Main outcome measure: survival to discharge

14. There is 8.9% reduction in overall mortality in TTA group compared to TTNA group despite higher median ISS at 41 for TTA as compared to median ISS of 34 in TTNA group, but was not statistically significant (p = 0.35).

16. Using TRISS methodology, the TTA group also shows better outcome in term of TRISS probability of survival (Ps) compare to TTNA group. The results shows that in term of Ps > 0.5 the TTA group recorded 86.8% survivor compare to 79.7% in TTNA group. As for the Ps < 0.5 the TTA group recorded mortality of 53.3% compare to 83.3% mortality in TTNA group.

17. Discussion • Outcome has improved but difference is insignificant • Small sample size • Some confounding factors • Different level of experience and training of the EPs, surgeons, anaesthetists and medical officers (EM Med and others) • Availability of ICU • Pre hospital care issues

18. Challenges • Access block • ED • Main OT/Trauma and emergency OT • ICU bed • Variation in decision plan by different surgical specialists on duty • Trauma interest • Trauma sub-specialty • Primary team issue • Pre-hospital care

19. February 2012: Arrival of Trauma Surgeon Assoc Prof Dr Oliver Hautmann

20. Challenges tackled • Anesthetists listen to surgeons • Trauma and emergency OT opens 24/7 • Made ICU beds available for trauma case under trauma surgeon as primary consultant • Trauma surgeon involves in Trauma Team activation • Decision maker • Consulted by surgical specialists when he is not in-house • Creation of a Trauma Unit under Surgical Department

21. Closing the loop • Improving pre hospital care • Improving response time • New ambulances • Non hospital based ambulances • Development of HEMS • Improving staff competency • Doctors in ambulance • Credentialing of paramedics • Training of paramedics using standardized curriculum • Improving trauma triage and trauma team activation • Critical incidence review

22. Still poor activation of trauma team by pre • hospital care providers. • Issues are: • Lack of confidence • Training • Feedback from medical control • Dedicated pre hospital care providers • Dedicated personnel at the call centre • Lack of support from other pre-hospitalproviders Clinical skills training for paramedics

23. 7 new ambulances: 4 type A 3 TYPE b FULLY EQUIPPED

24. Helicopter emergency medical service (HEMS) • Involve G to G

25. Trauma subspecialty Role of CEP, MOH, Universities

26. Conclusion • Trauma team formation in UMMC improves trauma outcome • Smooth running of the trauma team protocol requires dedicated emergency physician and trauma surgeon or surgeon with special interest in trauma • Improvement in pre hospital care and development of trauma subspecialty either via surgery or emergency medicine specialty will close the loop for an efficient trauma system in UMMC

27. Thank you idzwan@ummc.edu.my