Defined as the phase of care necessary to get a patient from the point of injury or illness to the place of definitive treatment, prehospital care is becoming increasingly important in many parts of the world including Malaysia (Sikka and Margolis, 2005). As the economy progresses, health networks improves and people tend to live longer. Rapid urbanization occurs, with increasing numbers of people shifting out to larger cities.
Introduction to Malaysia
Malaysia covers an area of approximately 330 803 km2, consisting of Peninsular Malaysia and the states of Sabah and Sarawak, and Federal Territory Labuan in the northwestern coastal area of Borneo Island (Department of Statistics Malaysia, 2011c). Kuala Lumpur has a population density of 7089/km2; whereas interior places of the state of Sarawak, such as Belaga and Kapit, have a population density of merely 2 and 4/km2 (Department of Statistics Malaysia, 2011b).
As people are moving into cities, there are more trauma related emergencies, especially motor vehicle accidents, bringing a greater need for prehospital care services. Currently, only 10–30% of emergency cases are managed by existing prehospital EMS agencies—there is still a large proportion of patients that are brought in by passerbys or via their own transportation to the hospital.
Life expectancy for Malaysian males and females has been steadily improving from 71.5 years (2006) to 71.7 years (2010) for male, and 76.3 years (2006) to 76.6 years (2010) for female (Department of Statistics Malaysia, 2011c). The percentage of people aged 65-years-old and above has increased from 4.0% (2000) to 4.7% (2010) (Department of Statistics Malaysia, 2011c).
As people live longer, disease pattern changes, and this results in an increase in the number of cardiovascular disease cases. For example, in 2009, cardiovascular disease was the number one (16.1%) cause of death and accident-related injuries came the seventh (4.9%) cause of death (Ministry of Health Malaysia, 2011). The chance of survival from cardiovascular diseases is often influenced by time-dependent interventions. For example, a patient with acute ST-elevation myocardial infarction requires thrombolytic therapy as early as possible.
It is stipulated that the time frame from a patient's arrival at the emergency department to the initiation of thrombolytic therapy (known as the ‘door-to-needle’ time) should be within 30 minutes (Antman et al, 2004). In reality, the mean door-to-needle time shown in a recent single centre, local study in Malaysia, was approximately 105 minutes (Lee et al, 2008).
Similarly, for a cardiac arrest victim, chance of survival is dependent upon the prompt initiation of chest compression (Sasson et al, 2010). However, the ambulance response time in Malaysia varies from approximately 15.2 to 25.6 minutes, depending on the location and traffic congestion (Hisamuddin et al, 2007). This may indicate that public members play a crucial role in starting bystander CPR prior to the arrival of ambulances. In a small recent study, we found that bystander CPR was only performed in 9% of out-of-hospital non-traumatic adult cardiac arrest cases (Chew et al, 2008b).
Prehospital care: a complex system
According to Van Rooyen et al (1999), prehospital systems can be divided into five different types of system models. These five models are:
The details of each of these systems are described in Table 1. Based on the above classification, prehospital care in Malaysia can be considered as a complex system, with the hospital-based system as the oldest and main service provider. Most of these hospital-based EMS services are provided by the public or government hospitals. The Civil Defence Department is the second largest agency, providing 24-hour of prehospital coverage in most urban areas of every state in Malaysia. Private systems do play a minor role, but these are usually paid services provided by private medical centres. Jurisdiction-directed system is rudimentary in Malaysia, provided mostly by the police and fire department personnel. These personnel are not legally bound to provide medical care, and their main emphasis is on rapid transportation of emergency patients with bare minimum first aid provision. A volunteer-based system, on the other hand, is a well-established system, with the St John Ambulance Malaysia and the Malaysian Red Crescent being the main key players. This volunteer-based system, with their own training programmes and hardware (including vehicles), often serves as a reliable extension arm to complement services by the hospital-based system.
| System model | Description |
|---|---|
| Hospital-based system | In this system, the emergency medical services (EMS) personnel are trained and managed at the hospital level. This system is usually the easiest to initiate and maintain as medical control issues are less complicated and can be incorporated into the existing hospital system seamlessly. This type of system is commonly seen in newly developed systems |
| Jurisdiction-directed system | This system originates from the municipal or district level, and may be linked to the fire response, with contracted physicians providing medical oversight |
| Private system | This system, as the name goes, is maintained by private organizations |
| Volunteer system | This system is formed by a network of volunteers who are privately trained |
| Complex system | This system is a combination of any of the above system types and evolve secondary to resource limitation, as well as the need for shared resources. |
Ultimately, the aim of any prehospital care is to decrease the morbidity and mortality associated with sudden medical and traumatic emergencies (Sikka and Margolis, 2005). A technology-intensive model of prehospital care may not always be the most appropriate, and with its relatively high cost budget, this is beyond the capability of most developing countries.
Furthermore, high technology does not always translate into high-quality care (Garfield and Rodriguez, 1985). On the contrary, prehospital care must exist within a country's cultural and geopolitical framework and the boundary of its supporting health care infrastructure (Sikka and Margolis, 2005).
Therefore, it is imperative to study in-depth and understand the current level of infrastructure development and healthcare facilities in a country before embarking on the development of EMS. In fact, not only a great disparity exists in terms of the level of EMS development from country to country; even within a nation itself, the level of EMS development differs from one locality with another.
Malaysia and EMS
In Malaysia, a whole gamut of different EMS services exists, ranging from providing basic transportation (‘scoop and run’) only, to providing first aid or basic life support care up to offering advanced care with the presence of trained healthcare providers. In the interior parts of Sabah and Sarawak states, accessibility of health care is extremely limited, and sometimes impossible, especially at night and during bad weather. In areas such as these, developing critical infrastructure for initial resuscitation and stabilization, as well as efficient and effective retrieval medicine, may be the way forward.
Flying doctor services
In Sarawak, one of the ways to overcome this logistic difficulty is the use of the ‘Flying Doctor Services’ (FDS), introduced in 1973. The aim of this service is to provide basic health services to people living in remote areas. At that time, this service was operated by using three private helicopters that were rented on a contractual basis. This service covers up to 141 remote locations in rural parts of Sarawak, with approximately 70 000 outpatients, children and antenatal cases every year.
The FDS team comprises a medical officer, a medical assistant and two community nurses who visit the locations once every one or two months. The FDS also provides medical emergency evacuation (MEDEVAC) of seriously ill or injured patients from these remote localities to the nearest appropriate hospitals (Sarawak Government Portal, 2011). At present, the air medical services in Sarawak has been expanded to five helicopters; with the MEDEVAC services having two specific twin-engine helicopter on standby at all time and another three helicopters for uninterrupted FDS services.
Integrated resources
As mentioned by Sikka and Margolis (2005), prehospital care is only one part of a chain of integrated resources (Figure 1). For a healthcare system to improve, other components of this chain of resources must be developed in tandem. Therefore, public education (including education on basic life support), access to care, staff training, equipment, etc. must be maximized. By merely developing prehospital care, without developing these other components, may paradoxically result in fragmentation and wastage of resources.
Van Rooyen et al (1999) outlined 15 essential EMS components as stipulated under the Emergency Medical Systems Act (Table 2). Of these 15 components, Van Rooyen et al (1999) singled out seven components that should be implemented at the initial stage with gradual implementation of the other eight components as the system matures. The remainder of this article will discuss specific issues and challenges we face in these seven initial essential components.
| To be implemented in the initial stage |
|---|
| Manpower |
| Training |
| Communication |
| Transportation |
| Facilities |
| Access to care |
| Coordinated patient record-keeping |
| To be implemented gradually as the system matures |
| Critical care units |
| Public safety agencies |
| Consumer participation |
| Patient transfer |
| Public information and education |
| Review and evaluation |
| Disaster plan |
Manpower
Currently, prehospital care in Malaysia is manned by the paramedics and a driver; and occasionally but not necessarily, together with a medical doctor. Therefore, the staff that are involved in EMS have differing levels of knowledge, skills and competency. This can result in inconsistency of care, non-adherence to standard management protocol and inter-facility transfer policy.
Training
There is no standardized certification for prehospital care providers within Malaysia. The paramedics staffing the ambulances have formal training in general paramedical sciences, but are not necessarily trained in prehospital care (Hisamuddin et al, 2007). Most of the time, the driver has no formal medical training, and neither is he/she specifically trained to handle ambulances or EMS vehicles. As yet, there is no specific national prehospital care training institute. Although a few private institutions have started their own paramedical prehospital care training programmes, their curriculum is not a standardized curriculum.
Communication
In July 2007, the Malaysian government introduced the ‘one nation, one number’ system of the universal emergency number ‘999’ for all types of emergencies, regardless of whether it is health-related or nonhealth related (Chew et al, 2008b). This has made it easier for the public to activate the EMS as people do not need to remember too many numbers as they previously did—‘991’ for Civil Defence Department, ‘994’ for Fire and Rescue and ‘999’ for police. Nonetheless, prank calls are still a problem in more than 90% of the emergency number usage (Chew et al, 2008b) despite the active public awareness campaign that making prank calls is an offence punishable to a maximum fine of RM50 000 (£10 000), or imprisonment for a term not exceeding one year or both, under section 233 of the Malaysian Communications and Multimedia Act 1998 (Malaysian Communications and Multimedia Commission, 2011).
Another problem faced is the lack of uniformed EMS communication between different agencies. Each individual agency is relying on their own communication system of call-receiving and dispatching of EMS teams (Hisamuddin et al, 2007). This can potentially result in incoordination, inappropriate transfer, overlapping and wastage of resources (for example, when more than one ambulance arrives at the site of accident to transport one victim). Realizing this difficulty, the Malaysian government introduced the Government Integrated Radio Network (GIRN) last year. Basically, GIRN is an attempt to close this inter-agencies communication gap between the fire department, the police, the EMS and other public safety agencies. However, the main limiting factor of GIRN is its restricted coverage to certain densely populated areas only.
Transportation and facilities
There are few types of land ambulances in Malaysia (Table 3). The high-end types (Grade A or A1) are available in larger cities and Grade B are available in district hospitals or rural health centres.
| Types of land ambulances | Description |
|---|---|
| Grade A1 | All of Grade A equipment plus specialized machines such as neonatal incubator, mobile intensive care facilities, etc |
| Grade A | All of Grade B equipment plus transport ventilator, defibrillator and cardiac monitor |
| Grade B | Equipped with basic equipment such as immobilization and splints for suspected fractures, trauma kit including cervical collar, triage card and scoop stretcher |
| Others | Basic patient transport service van (PTSV), four-wheel drive, etc. |
‘In Malaysia, as yet, there is no specific national prehospital care training institute. Although few private institutions have started their own paramedical prehospital care training programmes, their curriculum is not a standardized curriculum’
Access to care
Since the 1970s, the Ministry of Health in Malaysia has taken steps to establish an extensive network of health care services in the country. Currently, a total of 97% of the rural population have access to healthcare services within a 3 km radius from their residence; and in East Malaysia, more than 50% of rural residents have access to health care services within a 5 km radius (Krishnaswamy et al, 2009). In areas such as the interior parts of Sarawak, health care services are limited. In such cases, the concept of self-care and community active participation is vital. The Sarawak state government, for example, has started training community health volunteers under the village health promoter (VHP) programme to supplement the existing healthcare services provided by the government (Sarawak Government Portal, 2011).
Coordinated patient record-keeping
There is no single coordinated patient recordkeeping system in Malaysia. Not only do patients record notes in private medical centres differ from that in government healthcare centres, but even within government healthcare services itself, patient record system differs from centre to centre. In remote areas, where it is difficult to retrieve the previous and concurrent treatment given in another centre, this can pose considerable diagnostic and therapeutic problems.
Again, a unique feature in the Sarawak state is the use of ‘home-based’ medical records. This system was introduced in the 1970s initially for the child health records (including immunization records), and then it was extended in the 1980s for antenatal records. Since 1992, it has been extended for the entire outpatient medical cases. The main advantage of this system is that it ensures a seamless continuum of care for the patient as the patient themselves hold a copy of all treatment given in any government centres in the state of Sarawak (Sarawak Government Portal 2011). Unfortunately, over the recent years, a few medico-legal issues have cropped up, posing huge challenges to this ‘home based’ medical records system. This has prompted the government to look into using digital system as the way forward.
Conclusion
Although prehospital care services in Malaysia have improved considerably, there is still much room for further improvement. The bottom line, however, is that because of the varied socio-cultural and geographical differences in different parts of Malaysia, there is no ‘one-size-fit-all’ system for the entire prehospital care development. In fact, any measure considered for the development of prehospital care in Malaysia should ensure its continuity and sustainability, and not just a mere ‘stop-gap’ measure.