Prehospital care in Malaysia: Issues and Challenges 

ABSTRACT

Prehospital care is defined as the phase of patient care from the point of injury or illness to the place of definitive treatment. As such, it is imperative that the right patient is transported to the right place of care within the right time frame via the right mode of transportation by the right personnel. In this article, the authors explore seven components that are essential in the initial stage of any prehospital care system development, viz., the components of manpower, training, communication, transportation, facilities, access to care and coordinated patient record keeping. The authors then address issues and challenges in these seven components within the Malaysian context. Because of geopolitical and logistic differences from one locality with another, it is not possible for a “one-size-fit-all” solution to these issues and challenges within Malaysia. Ultimately, any effort to develop the prehospital care system should not be a mere stopgap measure, rather, it should address fundamental root problems in order to ensure sustainability and continuity of effort.

    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 network 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). Large cities such as 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, 2011a). As people are moving into cities, there is more trauma related emergencies, especially motor vehicle accidents and thus, a greater need for prehospital care services. Currently, only 10–30% of emergency cases are managed by existing prehospital EMS agencies. Thus, there is still a large proportion of patients that are brought in by passerbys or via their own transportation to the hospitals.

   Life expectancy for Malaysian male and female 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, 2011b). The percentage of people aged 65-years-old and above has increased from 4.0% (2000) to 4.7% (2010) (Department of Statistics Malaysia, 2011b).

   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 diseases was the number one (16.1%) cause of death in the Malaysian Ministry of Health hospitals and accident-related injuries came the seventh (4.9%) cause of death (Ministry of Health Malaysia, 2011). The chance of survival in these 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 30minutes (Antman et al, 2004) although in reality, the mean ‘door-to needle’ time shown in a recent single centre, local study in Malaysia was about 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 min to 25.6 min depending on the location and traffic congestion (Hisamuddin et al, 2007) which 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 l Hospital-based systems l Jurisdiction-directed systems l Private systems l Volunteer systems l Complex systems. 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.

    Jurisdictiondirected system is rudimentary in Malaysia, provided mostly by the police and fire department personnel. These personnel are not legally bound to provide medical care. 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 Malaysian Red Crescent and the St John Ambulance Malaysia 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.

   Ultimately however, the aim of any prehospital care is to decrease the morbidity and mortality associated with sudden medical and traumatic emergencies (Sikka and Margolis, 2005). technology intensive model of prehospital care may be not always 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 have in-depth study and to 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 stabilisation, as well as efficient and effective retrieval medicine, may be the way forward.

 

MANPOWER

Prehospital care in Malaysia is currently usually 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.

 

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 3km radius from their residence and in East Malaysia, more than 50% of rural folks have access to health care services within a 5km 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).

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 3km radius from their residence and in East Malaysia, more than 50% of rural folks have access to health care services within a 5km 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).

 

 

CONCLUSION

In summary, 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 sociocultural 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.

 

Research By
Keng Sheng Chew – Senior Lecturer/Emergency Physician, Emergency Medicine Department, School of Medical Sciences, Universiti Sains Malaysia.
Hiang Chuan Chan – State Emergency Physician of Sarawak/Head of Department, Emergency Medicine Department, Sarawak General Hospital

Prehospital care in Malaysia: Issues and Challenges