Trauma System in Malaysia: An experience
in University Malaya Medical Centre
Assoc Prof Dr Mohd Idzwan bin Zakaria
Consultant Emergency Physician UMMC
President College of Emergency Physicians
Academy of Medicine Malaysia
Effective trauma system
Effective prehospital care
providers and protocols
Designated trauma centres
Communication and
coordination
J. Duranteau :Trauma System in Europe
http://www.darbicetre.com/traumatologie/pdfcours/2011
_JDuranteau_24_Trauma_systems_in%20Europe.pdf
University Malaya Medical Centre
(UMMC)
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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
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Highly congested area
Population density: 3,700/km2
UMMC
Objectives
Clinical risk management
Decision making by
Junior MO
Late referral
Late decision
making
Poor communication
Poor prioritization
System
improvement
Blame
game
Patient safety
Redistribution of trauma care
roles
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Resuscitative and critical care phases
Emergency physicians
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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
Surgeon then act as team leader
once arrived
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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
Study on outcome
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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).
COMPARISON OF OUTCOME (MORTALITY) FOR
BOTH GROUPS
77.9%
PERCENTAGE %
80%
69%
70%
60%
50%
Alive
31%
40%
22.1%
30%
20%
10%
0%
TTNA
TTA
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
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Outcome has improved but difference is insignificant
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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
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Access block
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Variation in decision plan by different surgical specialists
on duty
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ED
Main OT/Trauma and emergency OT
ICU bed
Trauma interest
Trauma sub-specialty
Primary team issue
Pre-hospital care
February 2012: Arrival of
Trauma Surgeon
Assoc Prof Dr Oliver Hautmann
Challenges tackled
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Anesthetists listen to surgeons
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Trauma surgeon involves in Trauma Team activation
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Trauma and emergency OT opens 24/7
Made ICU beds available for trauma case under trauma
surgeon as primary consultant
Decision maker
Consulted by surgical specialists when he is not in-house
Creation of a Trauma Unit under Surgical Department
Closing the loop
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Improving pre hospital care
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Improving response time
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Improving staff competency
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New ambulances
Non hospital based ambulances
Development of HEMS
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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Clinical skills
Still
16 poor activation of trauma team by pre
hospital care providers.
training for
14
Issues are:
paramedics
12 •Lack of confidence
10 •Training
•Feedback from medical control
Emergency physician
8 •Dedicated pre hospital care providers
6 •Dedicated personnel at the call centre
Registrar
•Lack of support from other pre-hospital providers
4
Ambulance team
2
0
January
Feburary
March
April
May
June
July
August
September
October
November
December
January
Feburary
% Activation
Trauma team activators
Helicopter emergency medical service (HEMS)
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Involve G to G
Trauma subspecialty
MMed
Trauma
Subspecialty
• Surgery
• Emerg Med
• Surgery
• Emerg Med
• Trauma
surgeon
• Trauma
physician
Conclusion
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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