SGT 2 Group A

Equipments in GP.
Tips and tools for creating and presenting wide format
slides

 Each of GPs has access to a fully

equipped doctors bag for emergency
care and routine visits and the bag
contains:

Reference : The Royal Australian College of General Practitioners

Equipments
auriscope
disposable gloves
equipment for maintaining an
airway in both adults and
children
in-date medicines for medical
emergencies

 ophthalmoscope
practice stationery (including
prescription pads and
letterhead)

 sharps container
sphygmomanometer
stethoscope
syringes and needles
in a range of sizes

 thermometer
tongue depressors
torch

Medicine
To ensure patient safety, it is important that GPs are familiar with the
medicines that are included in their doctors bag, including the general
usage, suggested dosage and possible side effects. It is recommended
that GPs seek appropriate and ongoing education on these as
required.Amended in May 2013.
Suggested emergency medicines include:
adrenaline
aspirin
atropine sulphate
benztropine mesylate
benzylpenicillin
chlorpromazine or haloperidol
diazepam

ergotamine maleate
frusemide
glucose 50% and/or glucagon
glyceryl trinitrate spray or tablets
hydrocortisone sodium succinate or dexamethasone
metoclopramide hydrochloride
morphine sulphate or appropriate analgesic agent
naloxone hydrochloride
prednisone
promethazine hydrochloride
salbutamol aerosol.

 Equity of access means that all people have the

information they need-regardless of
age, education, ethnicity, language, income, physical limitations or
geographic barriers.

It means that everyone should have a fair opportunity

to attain their full health potential and aim to reduce or
eliminate the factors that are considered avoidable and
unfair.

 As defined in the National Health Strategy the principle

of equity means that services are accessible on the
basis of need rather than on geographical location or
ability to pay.
Specifically in relation to health care, that equity is
defined as:
Equal access to available care for equal need
Equal utilisation for equal need
Equal quality of care for all

 Socio-economic status
Overcrowding and lack of bed availability in public
hospitals
People in rural and remote areas (geographic isolation)
Cultural and religious beliefs

The National Health Strategy also

states that the important steps to
ensure greater equity are:
Implementing uniform rules for eligibility
and charges for services across the
country
Measures to reduce waiting-times for
those availing of public services
Giving special attention to certain
disadvantaged groups

Good Standards of
Care in Primary Care

Section I : Community Involvement

and Integration
The primary care center and other health care and civic centers
cooperate and partner to identify the health care problems and
services needed within the region and community.
Community hospital backup and medical transportation services
are available, if needed, from within the regional health care
delivery system.
The primary care center works collaboratively with other
organizations and health agencies to identify and include
vulnerable populations in community health programs

 In conjunction with community planning, each primary care

center defines and measures its achievement in meeting
community goals of care.
The primary care center participates actively as a member of its
community and region.
The primary care center participates in a variety of health
promotion and disease prevention programs with its community.
The primary care center includes community participants in its
governance structure.
The primary care center regularly solicits community perceptions
related to its services and primary care center matters.

Section II : Patient-Centered
Services
Basic and essential services, as needed by the primary care
centers population, are provided.
The primary care center informs patients and families about its
care and services and how to access those services.
The primary care center designs patient care processes to reduce
the risk of unsafe patient care.
Patient informed consent is obtained through a process defined
by the primary care center and carried out by trained staff.

 All patients are assessed and reassessed at appropriate intervals

to determine their response to treatment and compliance with
treatment, identify complications, and plan for continuing care or
determine that treatment is complete.
Laboratory and diagnostic imaging services are available on site
or readily available through arrangements with outside sources to
meet patient needs.

 The primary care center provides care and treatment using

uniform care processes that ensure a high level of patient care.
There is a process to integrate and coordinate the care provided to each patient.
The care provided to a continuing care patient is planned, revised when indicated,
and documented in the patients record and made accessible to all the patients
care providers.

Medication use in the primary care center is organized to meet

patient needs and complies with applicable laws and regulations.

 The primary care center addresses end-of-life care appropriate to

the patients condition and needs or refers the patient to outside
sources of appropriate care.
Education supports patient and family participation in care
decisions and care processes.

Section III : Organization and

Delivery of Services
A senior manager or director is responsible for operating the
primary care center and complying with applicable laws and
regulations.
Continuity of care and coordination of care are provided from
initial assessment through care, treatment, and follow-up.
An established procedure(s) governs patient consultations and
referrals or transfers to another level of care, health professional,
or setting.
Confidentiality, security, and integrity of data and information are
maintained.

 The primary care center initiates and maintains a patient record

for every individual assessed or treated.
The primary care center uses a coordinated process to reduce the
risks of endemic and epidemic infections in patients and health
care workers.
The primary care center identifies the procedures and processes
associated with the risk of infection and implements strategies to
reduce infection risks.

acute disease
management
World Health Organization (WHO)|Health systems and services: The role of
acute management.

Definition ACUTE CARE

Standard medical definitions for acuity emphasize the singular attribute
of time pressure.

Acute services therefore include all promotive, preventive, curative,

rehabilitative or palliative actions, whether oriented towards individuals
or populations, whose primary purpose is to improve health and whose
effectiveness largely depends on time-sensitive and, frequently, rapid
intervention.

 A reasonable working definition of acute care would include the most

time-sensitive, individually-oriented diagnostic and curative actions
whose primary purpose is to improve health

The termacute care encompasses a range of clinical health-care

functions, including emergency medicine, trauma care, pre-hospital
emergency care, acute care surgery, critical care, urgent care and
short-term inpatient stabilization

Domains in acute care

 aTreatment of individuals with acute surgical

needs, such as life-threatening injuries, acute
appendicitis
or
strangulated
hernias.
bTreatment of individuals with acute life- or
limb-threatening
medical
and
potentially
surgical needs, such as acute myocardial
infarctions or acute cerebrovascular accidents,
or evaluation of patients with abdominal pain.
cAmbulatory care in a facility delivering medical
care outside a hospital emergency department,
usually on an unscheduled, walk-in basis.
Examples include evaluation of an injured ankle
or fever in a child.

 dTreatment of individuals with acute needs

before delivery of definitive treatment.
Examples include administering intravenous
fluids to a critically injured patient before
transfer
to
an
operating
room.
eCare provided in the community until the
patient arrives at a formal health-care
facility capable of giving definitive care.
Examples include delivery of care by
ambulance personnel or evaluation of acute
health problems by local health-care
providers.

 fThe specialized care of patients whose

conditions are life-threatening and who
require comprehensive care and constant
monitoring, usually in intensive care units.
Examples
are
patients
with
severe
respiratory problems requiring endotracheal
intubation and patients with seizures caused
by cerebral malaria.

AIM of Acute Care

(based on African Federation for Emergency Medicine and the Academic Emergency Medicine
Consensus Conference scheduled for May 2013)

Creating an acute care service delivery model for low- and middleincome countries that will function in parallel with preventive and
primary services. These acute care services will address both lifethreatening and limb-threatening problems as well as exacerbations of
priority noncommunicable diseases.
Improving coordination between deliverers of acute care services, such
as emergency physicians, surgeons and obstetricians, to deliver critical
acute care services efficiently and effectively.

AIM of Acute Care

(based on African Federation for Emergency Medicine and the Academic Emergency Medicine
Consensus Conference scheduled for May 2013)

Developing research methods to quantify the burden of acute care

diseases and injuries, including health economics and costeffectiveness components, to justify integrating acute care within
health systems.
Holding national and international discussions to encourage better
integration of acute care within local and national health systems

Summary
Acute care plays a vital role in the prevention of death and disability.
Primary care is not positioned, and is frequently unable, to assume this
role.
This is partly because of lack of appropriate metrics and coordination of
health service delivery.
Understanding acute care as an integrated care platform allows these
splintered areas to move forward with a single agenda as a unified front

Epidemiology of
Dengue Fever
1. Dengue Incidence, Prevention and Control
Program in Malaysia
Rose Nani Mudin
Head of Vector Borne Disease Sector, Ministry of Health Malaysia

2. http://wwwnc.cdc.gov/travel/notices/watch/dengue-malaysia

Dengue Incidence Rate and Case

Fatality Rate for Malaysia, 20002014

Number of Dengue Cases and

Deaths for Malaysia, 2000-2014

Dengue Virus Serotype in Malaysia,

1990-2014

Why is the incidence increasing?

Serotype shifts
Climate change rising temperatures, increasing rainfall, humidity
Rapid industrialisation in the past several decades
Widespread human movement the infected can easily spread the virus when they visit new
places
High Aedes breeding index
From MOH analysis, Polystyrene food containers, plastic bottles and tyres contribute the highest percentage of
breeding places.
Average Aedes Index for 2015 ranged between 1.5 to 2 %

Poor environmental cleanliness littering habit in the community, inapprpopriate solid waste
disposal

How to reduce it? PREVENTION!

Cover exposed skin by wearing long-sleeved shirts, long
pants, and hats
Use an insect repellent as directed
If you are also using sunscreen, apply sunscreen first and
insect repellent second
Do not use permethrin directly on skin

How to reduce it? PREVENTION!

Use permethrin-treated clothing and gear (such as boots, pants,
socks, and tents). You can buy pretreated clothing and gear or
treat them yourself
Stay and sleep in screened or air conditioned rooms
Use a bed net if the area where you are sleeping is exposed to
the outdoors
Avoid outdoor activities or use protection during the mosquito
peak periods: 5.30 8.00am and 5.30pm 8.00pm

7. Clinical Practice
Guideline (CPG)

 Evidence-based implies that the document or

recommendation has been created using an unbiased
and transparent process of systematically reviewing,
appraising, and using the best clinical research findings
of the highest value to aid in the delivery of optimum
clinical care to patients.

 A Clinical Practice Guideline (CPG) has been defined in

a very structured manner by the Institute of Medicine as
a systematically developed statement to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances.

 Evidence-based CPGs are a series of recommendations

on clinical care, supported by the best available
evidence in the clinical literature.
Usually produced at national or international levels by
medial associations or governmental bodies

 Example: CPG Management of Dengue Infection in

Adults, Revised 2nd Edition 2010 was produced by the
MOH and Academy of Medicine Malaysia
CPGs are available online for download:

http://www.moh.gov.my
http://www.acadmed.org.my

Purposes of CPG
To describe appropriate care based on the best available
scientific evidence and broad consensus
To reduce inappropriate variation in practice
To provide a more rational basis for referral
To provide a focus for continuing education
To promote efficient use of resources
To act as focus for quality control, including audit
To highlight shortcomings of existing literature and
suggest appropriate future research

How to critically appraise a CPG

Recent explosion of CPG leading to urgent need for
doctors to be able to critically appraise these guideline
for their:

Validity
Impact
Applicability to the care of individual patient

Finding the right guideline

1. Are the guideline recommendations valid
Were all relevant outcomes considered
Was the inclusion of appropriate studies complete
How was the conflict of interest managed
2. Who developed the guideline
3. What are the method of assessing the quality of evidence
4. What are the recommendations
How strong are the recommendations
Are the recommendations pragmatic
Are the recommendations applicable to your patient

1. Are the guideline recommendations valid

Were all relevant
outcomes considered?
Overall and disease
specific survival
Quality of life
Absence of complication
Therapy related adverse
events

Was the inclusion of

appropriate studies
complete?
CPG should be based on
systematic review of
current best evidence
Systematic review
methodology are well
established included
predefined inclusion &
exclusion criteria,
comprehensive literature
search
Higher evidence of study
design: Randomized
controlled trials (RCT)

How was the conflict of

interest managed?
Financial conflict
Intellectual conflict

2. Who developed the guideline

Different subspecialties identified in the guideline panel,
involve both specialized knowledge in content area and
evidence based medicine or research methodology

3. What are the method of assessing the quality of

evidence
One of the central issues that determine the strength of
recommendation is the quality of evidence
There are variety of rating system exists
Level of evidence rating system by the Centre of EvidenceBased Medicine in Oxford
The Catalonian Agency for Health Technology assessment &
Research (CAHTAR) Spain
U.S/Canadian Preventive Services Task Force
Irrespective whatever system is used, the quality of evidence
should be determine and graded

BIAS

Well-recognized dimensions of the quality of evidence are

The study design (example: RCT) and
Study limitation (allocation, concealment, blinding, completeness of follow up)

GRADE approach
Further
recognized
imprecision,
indirectness,
inconsistency
and
outcome
reporting
bias
as
dimensions of quality evidence
Quality of evidence: The extent to which our confidence
in an estimate of treatment effect is adequate to
support particular recommendation
4 categories: High, moderate, low, very low

Quality assessment criteria

Quality of
evidence

Study
design

Lower if

Higher if

High

Randomized
trial

Study limitations

Large effect (e.g., RR 0.5)

Very large effect (e.g., RR 0.2)

Moderate
Low
Very low

Inconsistency
Observational
study

Indirectness
Imprecision
Publication bias

Evidence of dose-response
gradient
All plausible confounding
would reduce a
demonstrated effect

Conceptualizing quality
High

Further research is very unlikely to change our confidence in the

estimate of effect

Moderate

Further research is likely to have an important impact on our

confidence in the estimate of effect and may change the
estimate

Low

Further research is very likely to have an important impact on

our confidence in the estimate of effect and is likely to change
the estimate

Very low

Any estimate of effect is very uncertain

4. What are the recommendations

How strong are the
recommendations?
High quality of evidence
Balance of benefit to
harm
Patient value and
preferences
Cost to the healthcare

Are the
recommendations
pragmatic?
Feasibility of guideline
implementations
Implications to the
health care system
(economic implications)

Are the
recommendations
applicable to your
patient?
Consider patient
demographics

GRADE approach
Strength of recommendation: Reflects the extent to
which we can, across the range of patients for whom
the recommendations are intended, be confident that
desirable effects of a management strategy outweight
undesirable effects
2 categories: Strong or weak/conditional

Strength of recommendations
Desirable effects are
Health benefits
Less burden
Savings

Undesirable effects are

Harms
More burden
Costs

Developing recommendations

Conclusion
CPG play a critical role in guiding the evidence based
clinical practice
We should have skills and knowledge to critically appraise
a guideline before applying it to the care of patients

1. Methodology
2. Levels of evidence
3. Grades of recommendation

PUBLIC HEALTH
ADVISORY

WHAT IS PUBLIC HEALTH ADVISORY ?

According to
McGraw-Hill Concise Dictionary of Modern Medicine.
2002 by The McGraw-Hill Companies, Inc.
A statement containing a finding that a release of
hazardous substances poses a significant risk to human
health recommending measures to be taken to decrease
exposure and eliminate or substantially mitigate the risk
to human health

Health Advisory Panel Panel

Penasihat
PENGERUSI
Masyarakat (11)

NAIB PENGERUSI
Ahli Klinik Kesihatan (5)
Doctor in charge

Dentist

Medical attendant

Staff nurse

Radiologist

 Chairman of Health Advisory Panel consist of 11

members
They are public society whom does not have a medical
background, e.g ; businessman
Malaysia health advisory panel only applicable to
government health clinic and does not involved in
private general practitioner

 Each year, every Klinik Kesihatan (KK) will receive some

amount of budget from Kementerian Kesihatan Malaysia
(KKM) to conduct a program for the society who live
nearby the KK area.
It is based on the current public health problem that has
been rise in the certain area.
The objective is to establish an important public health
relation with the clinic and to reduce the morbidity rate

HEALTH ADVISORY FOR

WORKPLACES DURING
HAZE
MINISTRY OF HEALTH,
MALAYSIA

 Haze is a situation where there is pollution to the air by

suspended particulate matter. The various determinants
of air pollution are, Sulphur Dioxide, Nitrogen Dioxide,
Ozone, Carbon Monoxide and PM10.
The fine particulate matter or PM10 (particulate of size
10 micron and below) is the main concern as it may
lead to adverse health conditions.

 Air quality is determined by the Air Pollutant Index

which is measured by the Department of Environment,
Ministry of Natural Resources and Environment.
The Occupational Safety and Health Act 1994, stipulates
that it is the responsibility of the employer to ensure the
safety, health and welfare of the employee.
The employer is thus responsible to ensure that
preventive measures are taken for employees who are
performing their tasks during the haze.

How private health

care obtain advisory
from MOH?
Answer from Dr Mustapha Ramdhan,
Poliklinik Kembar, Chemor

 GP clinic obtain advisory from Education department of

MOH. For example, updated management (CPG) .
CPG update courses/seminar also are provided by health
organization eg. Malaysian Medical Council (MMC).
Not compulsory to attend the courses but private gp is
recommended to attend the course (by own expenses).

 It is seldom for JKN (Jabatan Kesihatan Negeri) to send

advisory to inform about updated management on
particular medical condition or new issue eg certain
epidemic.

Doctor to patient ratio

in different countries

 About 44% of WHO Member States report to have less

than 1 physicianper 1000 population
Health workers are distributed unevenly across the globe.
Countries with the lowest relative need have the highest
numbers of health workers, while those with the greatest
burden of disease must make do with a much smaller
health workforce.
The African Region suffers more than 24% of the global
burden of disease but has access to only 3% of health
workers and less than 1% of the worlds financial
resources.

Density of physicians: Total number per 1000 of

population

Countries

Density per 1000 population

Year

Ethiopia

0.025

2009

Bangladesh

0.356

2011

Cambodia

0.169

2012

Indonesia

0.204

2012

Thailand

0.393

2010

India

0.702

2012

Malaysia

1.198

2010

Japan

2.297

2010

United States

2.452

2011

United Kingdom

2.801

2013

Australia

3.273

2011

Russian Federation

4.309

2006

Qatar

7.739

2010

United Kingdom
In the United Kingdom, patients can access primary
care services through their localgeneral practice,
community pharmacy, optometrist,dental surgeryand
community hearing care providers.
Services are generally provided free-of-charge through
theNational Health Service (NHS).
In the UK, unlike many other countries, patients do not
normally have direct access to hospital consultants and
the GP controls access to secondary care.

Canada
In Canada, access to primary and other healthcare
services are guaranteed for all citizens through
theCanada Health Act.

Nigeria
In Nigeria, healthcare is a concurrent responsibility of
three tiers of government.
Local governments focus on the delivery of primary care
(e.g. through a system of dispensaries), state
governments manage the various
generalhospitals(secondary care), while the federal
government's role is mostly limited to coordinating the
affairs of theFederal Medical Centresand university
teaching hospitals (tertiary care).

 Based on a survey of primary care doctors in 10

countries, in the U.S.the only country in the survey
without universal health coverage59 percent of
physicians said their patients often have trouble paying
for care. Far fewer physicians in Norway (4%), the U.K.
(13%), Switzerland (16%), Germany (21%), and
Australia (25%) reported affordability was a concern for
their patients.

1 Care for 1 Malaysia

1Care for 1 Malaysia : restructuring

the Malaysia health system
In strengthening the health care system to meet the
challenges posed by demographic & epidemiologic
transition, higher expectations of the population and
escalating health care cost,
the Ministry of Health has proposed 1Care for 1Malaysia in
2009 - a restructuring of the countrys health care system to
align it with Malaysias aspiration to become a high income
nation.

Current Challenges in Malaysian

Health System
1. Lack of integration
2. Changing trends in disease and socidemography
pattern
3. Greater expectations for quality services
4. Dependency on govt. subsidised services
5. Discrepancy of health outcomes related to accessibility
and affordability
6. Limited appraisal and reward systems for performance
7. Conflicts of interest

1 Care Concept
1Care is restructured national health system that is
responsive and provides choice of quality health care,
ensuring universal coverage for health care needs of
population based on solidarity and equity

Features of proposed model

(1care) :
BETTER
than system
current
system
Strength of current
will be
preserved
Stronger stewardship role for MOH & government
Separation of purchaser-provider functions
Integration of health care providers & services
- Gaining of numbers, expertise, & skills through
integration
More responsive to population health needs &
expectation through increased autonomy
Payments linked closely to performance of provider

Components of 1Malaysia Care

1. Delivery System Reforms
Increase quality of care
Family doctor for each individual

3. Healthcare
Financing Reforms
introduction of health
insurance scheme

2. Organisational Reforms
Public private integration
Public sector autonomy

91

Main Sources of Health Financing

Targets of 1 Care
Universal coverage
Integrated health care delivery system
Affordable & sustainable health care
Equitable (access & financing), efficient, higher quality
care & better health outcomes
Effective safety net
Responsive health care system
Client satisfaction

Benefits to Individuals
Access to both public & private providers
Reduced payment at the point of seeking care
Care nearer to home
Increased quality of care & client satisfaction
Better health outcome
Higher work productivity

Benefits to Employers
Relieve burden to reimburse worker or give loan for medical
spending
Relieve burden to cover work and non-work related illnesses
(beyond SOCSO)
Pay low contributions to cover employee and family
Reduce administration to process medical benefits
Avoid systems in which unnecessary care leads to higher
expenditure e.g. PHI, MCO & Panel doctors
Healthier workforce and higher productivity

Benefits to health care providers

Bridge the gap between remuneration and work load among
health workers in the public and private sectors.
Creates more effective demand for healthcare
Re-address distribution of health staffs through the provision of
specific incentives
Defined standards of care
Ensure appropriate competency through training credentialing
and privileging
Reduce brain-drain, increase available pool of providers

References
Ministry of Health Malaysia, 10th Malaysia Plan (20112015)
10th Malaysian Health Plan Conference
Health Situational Analysis for Medical Program 10MP