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