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 (no of beds)

128 (30,969) 130 (32,149) 130 (33,004)

No of Private Hospitals (no of beds)

NA 195 (11,291) 209 (11,689)

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  

1   Normal  Deliveries   13.99%  

2   ComplicaCons  of  Pregnancy,  Childbirth  and  the  Puerperium  

12.77%  

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%  

Top  Ten  Causes  of  HospitalizaCon  in  Malaysian  Ministry  of  Health  Hospitals  2008

Reference:  Health  Facts  2008.  Ministry  of  Health,  Malaysia  Official  Website.  URL:  www.moh.gov.my  

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%  

Top  Ten  Causes  of  Deaths  in  Malaysian  Ministry  of  Health  Hospitals  2008

Reference:  Health  Facts  2008.  Ministry  of  Health,  Malaysia  Official  Website.  URL:  www.moh.gov.my  

Chest pain Call 999 EMS Response Triage Plan

For PCI

Fibrinolysis

Patient’s symptoms

5 min after onset

Advice S/L GTN q5min, max 3 tablets

Dispatch

1 min

EMS Arrival within 8 min

EMS Transport

12-lead ECG

? Pre-hospital thrombolysis

Door to Needle time: 30 min

Door to Balloon time: 90 min

Inter-facility transfer

Inter-facility transfer

Cardiopulmonary Resuscitation Automated External Defibrillator

Flow  Chart  of  The  Emergency  Management  of  Acute  Coronary  Syndrome  

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   HEALTH  CLINIC  PHONE  NUMBER  

JPA  3  

TELEKOM    OPERATOR  

HOSPITAL  PHONE  NUMBER     991  

JPA  3  TEAM  EMERGENCY  DEPARTMENT  

HEALTH  CLINIC  PARAMEDIC  

HOSPITAL  OPERATOR  

• 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  1998,  which  carries  a  fine  of  up  to  RM50,000  or  up  to  five  years  jail  or  both.  

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.  

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

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.  

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.  

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  

Bicycle  and  Motorcycle  Squad  Around  Klang  Valley  Vicinity  As  A  Stop-­‐Gap  

Measure  

“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  

•  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.  

Cardiopulmonary  ResuscitaCon  

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  

Outcome  In-­‐hospital   30-­‐day*  

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  

Na=onal  Cardiovascular  Disease  Database  (NCVD)  

ElecCve  (n=7,439)  

                   Staged  PCI  

90.32  %  

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  %  

Baseline  (n=8,236)  PCI  Status  

NCVD-­‐PCI  Registry  Results  

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  

Conclusion  

Thank  You