1. 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

2. Effective trauma system
Effective prehospital care
providers and protocols
Designated trauma centres
Trained trauma specialists
and paramedic
Rehab facilities
Communication and
coordination
Trauma registry
J. Duranteau :Trauma System in Europe
_JDuranteau_24_Trauma_systems_in%20Europe.pdf
Research programme

3. University Malaya Medical Centre (UMMC)
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

4. Highly congested area
Population density: 3,700/km2

5. Come on Malaysians!!
Let me pass

6. UMMC

7. UMMC

8. Objectives Establishment of a trauma team in UMMC
Trauma outcomes after trauma team
Current improvement activities
Closing the loop

9. Clinical risk management
Decision making by
Junior MO
Late referral
Poor communication
Poor prioritization
Late decision
making

10. Blame game
System improvement
Patient safety

11. Emergency physician As team leader Before arrival of surgeon
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)
Emergency physician
As team leader
Before arrival of
surgeon
Steven M. Green, Trauma Is Occasionally a Surgical Disease: How Can We Best Predict When?; Annals of Emerg Med. 2011; 58(2):

12. This is our issue in ED initially
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 Best
Predict When?; Annals of Emerg Med. 2011; 58(2):
This is our issue
in ED initially

13. Study on outcome
1st January until 31st July 2011 (trauma team activated group: TTA)
7 months
Compared with 9th May 2010 until 19th December (trauma team non activated: TTNA)
Samples with ISS > 15
Main outcome measure: survival to discharge

14. 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).

16. 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.

17. 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

18. Challenges Access blockED
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

19. February 2012: Arrival of Trauma Surgeon
Assoc Prof Dr Oliver Hautmann

20. 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

21. 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

22. Clinical skills training for paramedics
Still poor activation of trauma team by pre
hospital 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
Clinical skills training for paramedics

23. 7 new ambulances:
4 type A
3 TYPE b
FULLY
EQUIPPED

24. Helicopter emergency medical service (HEMS)
Involve G to G

25. Role of CEP, MOH, Universities
Trauma subspecialty
MMed
Surgery
Emerg Med
Trauma
Subspecialty
Trauma surgeon
Trauma physician
Role of CEP, MOH, Universities

26. 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

27. Thank you