trauma system in malaysia: an experience in university malaya medical centre

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

Assoc Prof Dr Mohd Idzwan bin ZakariaConsultant Emergency Physician UMMC

President College of Emergency PhysiciansAcademy of Medicine Malaysia

Effective trauma system

Effective prehospital care providers and protocols Designated trauma centresTrained trauma specialists

and paramedic

Rehab facilities

Communication and coordination

Trauma registry

Research programme

J. Duranteau :Trauma System in Europehttp://www.darbicetre.com/traumatologie/pdfcours/2011_JDuranteau_24_Trauma_systems_in%20Europe.pdf

Tertiary referral centreOldest university hospital in MalaysiaGovernment funded public hospital Approximately 1700 nurses and paramedics and 800

doctorsAnnual patients’ attendance: 100,000/yearCatchment area for pre hospital care: 25km radius

University Malaya Medical Centre (UMMC)

Highly congested area Population density: 3,700/km2

Come on Malaysians!!Let me pass

UMMC

UMMC

Objectives

Establishment of a trauma team in UMMC

Trauma outcomes after trauma team

Current improvement activities

Closing the loop

Clinical risk management

Late decision making

Decision making byJunior MO

Poor communicationLate referral

Poor prioritization

Patient safety

Blame game

System improvement

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)Steven M. Green, Trauma Is Occasionally a Surgical Disease: How Can We Best Predict When?; Annals of Emerg Med. 2011; 58(2): 172-177

EMERGENCY PHYSICIANAS TEAM LEADER

BEFORE ARRIVAL OF SURGEON

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 BestPredict When?; Annals of Emerg Med. 2011; 58(2): 172-177

THIS IS OUR ISSUE IN ED INITIALLY

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

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).

0%

10%

20%

30%

40%

50%

60%

70%

80%

TTNA TTA

69%77.9%

31%22.1%

PERCENTAGE %

COMPARISON OF OUTCOME (MORTALITY) FOR BOTH GROUPS

Alive

Die

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.

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

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

February 2012: Arrival of Trauma Surgeon

Assoc Prof Dr Oliver Hautmann

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

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

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Trauma team activators

Emergency physician

Registrar

Ambulance team

Clinical skills

training for paramedics

Still poor activation of trauma team by prehospital 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-hospital providers

7 NEW AMBULANCES:

4 TYPE A3 TYPE B

FULLY EQUIPPED

Helicopter emergency medical service (HEMS)

Involve G to G

Trauma subspecialty

MMed•Surgery •Emerg Med

Trauma •Surgery •Emerg Med

Subspecialty •Trauma surgeon •Trauma

physician

Role of CEP, MOH, Universities

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

Thank you

idzwan@ummc.edu.my