PREHOSPITAL CARE IN

MALAYSIA: ISSUES AND

CHALLENGES

KS CHEW1, HC CHAN2
1School of Medical Sciences, Universiti Sains Malaysia

2Emergency Medicine Department, Sarawak General Hospital

Definition of Pre-hospital Care

• Is the phase of care necessary to get a patient from

the point of injury or illness to the place of definitive
treatment

• Increasingly important in many parts of the world

secondary to epidemiologic transition (Sikka and
Margolis 2005).

2
Introduction

• As the economy progresses health network

improves and people tend to live longer

• As people are moving out into cities, this in turn,

leads to a higher crime rate, more cases of motor
vehicle and other traumatic injuries, and thus a
greater need for pre-hospital care services.

3
Rapid Urbanisation

• Rapid urbanisation occurs with increasing number

of people shifting out to larger cities.
• Kuala Lumpur – current population density of 7,089
per square km
• Penang – 1,524 per sd km
• Interior places of the state of Sarawak such as
Belaga – 2 per sq km
• Kapit – 4 per sq km
(Department of Statistics Malaysia, June 2011)

4
Life Expectancy of Malaysians

• Male 71.5 years (2006)  71.7 years (2010)

• female 76.3 years (2006)  76.6 years (2010)
• The percentage of people aged 65 years old and
above has increased from 4.0% (2000) to 4.7%
(2010)

• (Department of Statistics Malaysia, 2011).

5
Changes in Disease Patterns

• As people lives longer, disease pattern changes,

and this results in an increase of the number of
cardiovascular-related disease cases.
• In 2009,
– CVD is the number one (16.1%) cause of death,
– Accidents-related injuries are the 7th (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.

6
Example of Time Dependent Interventions:
Door-to-Needle Time for STEMI
• Example: a patient with acute STEMI requires
initiation of thrombolytic therapy with the “door-to-
needle” time within 30 minutes (Antman et al, 2004)

• In reality, the mean “door-to-needle” time shown in

a recent local study in Malaysia was about 105
minutes! (Lee et al, 2008).

7
Example of Time Dependent Interventions:
Cardiac Arrest
• The chance of survival is dependent upon the
prompt initiation of chest compression (Sasson et
al, 2010).
• By directly compressing the heart, an adequate
intrathoracic pressure is created in order to
squeeze the blood out from the cardiac chamber to
perfuse the vital organs including the myocardium
and the brain (Berg et al, 2010).

8
Example of Time Dependent Interventions:
Cardiac Arrest
• Unfortunately, the ambulance response time in
Malaysia ranges from around 15.2 min to 25.6 min
depending on the location and traffic congestion
(Hisamuddin et al, 2007)
• Therefore, public members play a crucial role in
starting bystander CPR prior to the arrival of
ambulances.
• Unfortunately, in a recent small study, bystander
CPR was performed in 9% of OHA non-traumatic
adult cardiac arrest cases (Chew et al, 2008).
9
Types of Pre-hospital Care Models

• According to VanRooyen et al (1999), prehospital

systems can be divided into five different types of
system models. These five models are

1. Hospital-based systems
2. Jurisdiction-directed systems
3. Private systems
4. Volunteer systems
5. Complex systems

10
Five Types of Prehospital Care System
Models (1)
System Description
Model
Hospital- In this system, the EMS personnel are trained
based and managed at the hospital level. This system
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- This system originates from the municipal or
directed district level, and maybe linked to the fire
system response with contracted physicians providing
medical oversight.
11
Five Types of Prehospital Care System
Models (2)
System Description
Model
Private This system, as the name goes, is maintained by
system private organisations.
Volunteer This system is formed by a network of
system volunteers who are privately trained.
Complex This system is a combination of any of the above
system system types and evolve secondary to resource
limitation as well as the need for shared
resources.

(Adapted from VanRooyen et al 1999)

12
Pre-hospital Care in Malaysia: A Complex
System (1)
• Based on this 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.

13
Pre-hospital Care in Malaysia: A Complex
System (2)
• 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
• The police and fire personnel not legally bound to
provide medical care; mainly on rapid
transportation with bare minimum first aid provision
(scoop and run).
14
Pre-hospital Care in Malaysia: A Complex
System (3)
• 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.

15
 “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)

16
Is Technology-Driven System The Answer?

• Therefore, the technology-intensive

model of prehospital care may 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).

17
Pre-hospital care must exist within a
country’s cultural and geopolitical
framework and the boundary of its
supporting health care infrastructure
(Sikka and Margolis 2005)

18
Is Technology-Driven System The Answer?

• 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.
• 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.

19
The Situation in Malaysia

• 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.

20
The Situation in Malaysia

• 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 like these, developing critical infrastructure
for initial resuscitation and stabilization as well as
efficient and effective retrieval medicine may be the
way forward.

21
22
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.

23
Flying Doctor Services

• 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 utilising
three private helicopters that were rented on a
contractual basis.
• This service covers up to 141 remote locations in
rural parts of Sarawak with about 70,000
outpatients, children and antenatal cases every
year.

24
Flying Doctor Services

• This FDS team comprises of a medical officer, a

medical assistant and two community nurses who
visit the locations once every one or two months.
• Besides, 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, June 2011).

25
Flying Doctor Services

• At the current moment, 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

26
The Importance of Developing Other Chain
of Resources
• Prehospital care is only one part of a chain of
integrated resources.
• For a healthcare system to improve, other
components of this chain of resources must be
developed in tandem as well (e.g. public education
including BLS skills, access to care, staff training,
equipment, etc)
• By merely developing prehospital care without
developing these other components may result in
paradoxical fragmentation and wastages
27
 4.
Transportation
5. A&E Care

3. Pre-
6. Definitive hospital Care
Care:
Surgery, ICU,
etc 2.
Notification,
Response,
Dispatch
7. Chain of 1. Bystander
Rehabilitation
resources Care

the importance of a
seamless continuum of
care
28
Components of EMS Care

• VanRooyen et al (1999) outlined 15 essential EMS

components (see next slide).
• Out of these 15 components, seven components
that should be implemented at the initial stage with
gradual implementation of the other eight
components as the system matures.

29
Essential EMS Components

To be implemented in To be implemented as
the initial stage system matures
Manpower Critical care units
Training Public safety agencies
Communication Consumer participation
Transportation Patient transfer
Facilities Public information & education
Access to care Review and evaluation
Coordinated patient Disaster plan
record-keeping Mutual Aid
30
Essential EMS Components

To be implemented in To be implemented as
the initial stage system matures
Manpower Critical care units
Training Public safety agencies
Communication Consumer participation
Transportation Patient transfer

Facilities Public information & education

Access to care Review and evaluation
Coordinated patient Disaster plan
record-keeping Mutual Aid
31
Manpower

• At the current moment, the prehospital care in

Malaysia is usually manned by the paramedics and
a driver; and occasionally but not necessarily,
together with a medical doctor.
• The staffs that are involved in EMS have different
level of knowledge, skills and competency.
• This can result in inconsistency of care, non
adherence to standard management protocol and
inter-facility transfer policy.

32
Training

• There is no standardised certification for

prehospital care providers within Malaysia.
• The paramedics that are staffing the ambulances
have formal training in general para-medical
sciences but 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 a specifically trained to
handle ambulances or EMS vehicles.

33
Training

• Up to date, there is no specific national paramedic

training institute yet. Although few private
institutions have started their own paramedic
training programs, their curriculum is not a
standardized curriculum.

34
Communication

• In July 2007, the Malaysian government has

introduced the “One Nation, One Number” system
of universal emergency number „999‟for all types of
emergencies, regardless of whether it is health-
related or non-health related (Chew et al 2008).
• 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.

35
Communication

• Prank calls are still a problem in more than 90% of

the emergency number usage (Chew et al 2008)
despite the active public awareness campaign that
making prank calls is an offence punishable to a
maximum fine of RM50,000 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).

36
Communication

• Another problem that we face 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.

37
Communication

• Realising this difficulty, the Malaysian government

has recently introduced the “Government Integrated
Radio Network” (GIRN) since 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.
38
Transportation and Facilities

• There are few types of land ambulances in

Malaysia.
• 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.

39
Types of Land Ambulances In Malaysia

Types Description
Grade A1 All of Grade A equipment plus specialised
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.

40
Access to Care

• Since the 1970s, the Ministry of Health 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 folks have
access to health care services within a 5-km radius
(Krishnaswamy et al 2009)

41
Access to Care

• 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).
42
Coordinated Patient Record-keeping

• There is no single coordinated patient record-

keeping system in Malaysia.
• Not only that the patient‟s 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.

43
Coordinated Patient Record-keeping

• 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.

44
Coordinated Patient Record-keeping

• 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 immunisation
records), and then it was extended in the 1980s for
antenatal records and since 1992, it has been
extended for the entire outpatient medical cases.

45
Coordinated Patient Record-keeping

• 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).

46
Coordinated Patient Record-keeping

• 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.

47
Other Issues at the moment

• No legal provision safeguarding the interest of EMS

team and driver
• No “Good Samaritan Law”
• There is no Ambulance Act yet in Malaysia, a law
common in many countries to set the benchmark
for the emergency services.

48
Conclusion

• In summary, although prehospital care services in

Malaysia have improved considerably, there is still
much room for further improvement.
• 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.

49
Conclusion

• 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.

50