Triage in Emergency

Department
dr M arman Nasution SpPD

Waiting
room

Triage

Team leader

Definition of Triage
Triage

is the term derived from the

French verb trier meaning to sort or to
choose

Its the process by which patients

classified according to the type and
urgency of their conditions to get the
Right patient to the
Right place at the
Right time with the
Right care provider

Non

disaster: To provide the best care for

each individual patient.
Multi casualty/disaster: To provide the
most effective care for the greatest
number of patients.

Triage Categories

The primary objectives of an ED triage are

to (ENA,1992, P. 1):
1. Identify patients requiring immediate
care.
2. Determine the appropriate area for
treatment
3. Facilitate patient flow through the ED
and avoid unnecessary congestion.

Non disaster or E.D triage

4. Provide continued assessment

and reassessment of arriving and
waiting patients.
5. Provide information and referrals
to patients and families.
6. Allay patient and family anxiety
and enhance public relations.

Definition:

an incident, either natural or

human-made, that produces patients in
numbers needing services beyond
immediately available resources. May
involve a large no. of patients or a small
no. of patients if their needs place
significant demands on resources.
The key to successful disaster
management is to provide care to those
who are in greatest need first and just as
importantly, not provide care to to those
who have little or no chance of survival.
Correct triage is essential to accomplish
this goal
Disaster

Disaster

The triage team

Triage of Victims

not

- first victims to arrive are frequently

the most seriously injured.

Critical patients
Fatally Injured Patients
Non critical patients
Contaminated patients

Disaster

Type
Type
Type

1: Traffic Director (Non Nurse).

2: Spot Check
3: Comprehensive

Two-tiered

systems: intial screening by

RN who greets each patients on arrival,
perform a primary survey and
determine whether the patient is able to
wait for further assessment by a second
triage nurse.
Divide tasks among staff members,
internal triage and external triage

Types of E.D. triage system

1- Resuscitation
2- Emergent
3- urgent
4- less urgent
5- Non urgent
The Canadian E.D. Triage and Acuity Scale

Triage levels

Overview of three category triage acuity systems

category

Class 1

acuity

Emergent

Recommended
reassessment
continuous

Cardiopulmonary
arrest, severe
respiratory distress,
major burns, major
trauma, massive
uncontrolled bleeding
Coma, status epil..

Every 30
minutes

Abdominal pain, non

cardiac cp, multiple
fractures, lacerations,
renal calculi,

Every 1-2
hrs

Rash, chronic headache,

sprains, cold symptoms

Immediately life or limb

threatening

Class 2

Urgent
Requires prompt care, but
will not cause loss of life or
limb if left untreated for
several hours.

Class 3

Non urgent
And treatment but time is
not a critical factor

Examples

TRIAGE LEVELS
1- Resuscitation -- threat to life
Time to nurse assessment
IMMEDIATE
Time to physician assessment
IMMEDIATE
Cardiac and respiratory arrest
Major trauma
Active seizure
Shock
Status Asthmatics

Triage levels
2- Emergent
Potential threat to life,limb or function
Nurse Immediate , Physician <15 minutes

Decreased level of consciousness

Severe respiratory distress

Chest pain with cardiac suspicion

Over dose (conscious)

Severe abdominal pain

G.I. Bleed with abnormal vital signs

Chemical exposure to eye

Triage levels
3- Urgent
Condition with significant distress
Time Nurse < 20 min, physician < 30
min
Head injury without decrease of LOC but
with vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis

Triage levels
4- Less urgent
Conditions with mild to moderate
discomfort
Time for Nurse assessment <1h
Time for physician assessment < 1h
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac susp.
Depression with no suicidal attempt

Triage levels
5- Non urgent
Conditions can be delayed, no distress
Time for nurse and Physician assessment
more than 2h
Minor trauma
Sore throat with temp. < 39

An

across-the room assessment

The triage history
The triage physical assessment
The triage decision

Basic component of triage

An across the room assessment

To identify obvious life threat conditions
General appearance

Disability
(neurogenic)
Air way

Circulation
Breathing

Across the door

The triage nurse must scan the area
where patients enter
assessment
the emergency door, even while interviewing other patient.

The

triage antenna should be seeking clues to problems in

all people who enter the triage area
If any patient doesnt look right kindly but quickly
interrupt any current interaction and go investigate.

Air

way
Abnormal airway sounds, strider, wheezing
grunting
Unusual posture e.g.. Sniffing position, inability
to speak, drooling or inability to handle
secretion
Breathing
Altered skin signs, cyanosis, dusky skin,
tachypnic
bradypnea,
or apnea
periods,
retractions, use
Across
the
room
assessment
accessory muscles, nasal flaring, grunting, or
audible wheezes

Across the room assessment

Circulation

Altered skin signs, pale, mottling, flushing

Un controlled bleeding
Disability (neuro.)
LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid or hyper active muscle tone

Characteristics of triage nurse

Extensive

knowledge to emergency
medical treatment
Adequate training and competent
skills,language, terminology
Ability to use the critical thinker process
Good decision maker

Role of triage nurse

Greet patients and identify your self.
Maintain privacy and confidentiality
Visualize all incoming patients even while

interviewing others.
Maintain good communication between
triage and treatment area
maintain excellent communication with
waiting area.
Use all resources to maintain high
standard of care.

Role of triage nurse

Teaching

----- use of thermometer, first

aid ??? avoid lecturing.
Crowd control.
Telephone.
Communicate with team leader and
seek feed back on decisions.

Importance of re triage
Reassess

the patient within 1-2hours of

initial triage and continue to re assess
on a regular basis, patients who may
have presented without cardinal signs of
severe illness may develop them during
long waits.
Patients who appear intoxicated actually
may have life threatening problems
such as DKA, and should not be
permitted to keep it off in the waiting
room.

The last person in along line at triage may

have a serious medical problem that requires
immediate attention
Patient should wait no longer than 5 minutes
for triage
If in doubt about a category, choose the higher
acuity to avoid under triaging a patient

 Triage

is the term derived from the French verb

trier meaning to sort or to choose
Its the process by which patients are classified
according to the type and urgency of their
conditions to get the
Right patient to the
Right place at the
Right time with the
Right care provider

Triage:

To

treat the patients in the order of their

clinical urgency appropriately and timely

aim

Non

disaster: To provide the best care

for each individual patient.

Multi

casualty/disaster: To provide the

most effective care for the greatest
number of patients.

types

 Definition:

an incident, either natural or

human-made, that produces patients in numbers
needing services beyond immediately available
resources. May involve a large no. of patients or
a small no. of patients requiring significant
demand on resources.

The

key to successful disaster management is to

provide care to those who are in greatest need
first. Correct triage is essential to accomplish this
goal.

Disaster:

1.

Identify patients requiring immediate

care.

2.

Determine the appropriate area for

treatment

3.

Facilitate patient flow through the ED

and avoid unnecessary congestion.

Objectives -1:

4. Provide continued assessment and

reassessment of arriving and waiting
patients.
5. Provide information and referrals to
patients and families.
6. Allay patient and family anxiety and
enhance public relations.

Objectives -2:

Immediately

accessible

Sign

posted
Allow for patients examination
Privacy
Staff security
Fully equipped with Emergency equipment
Communication services

Triage area

Should be completed in 10 minutes

If it is going beyond 15 minutes call

for

additional nurse.
Accurate triage is key to the efficient
operation
Effective triage is based on knowledge,
skills and attitude of the triage nurse.
Pediatric cases record vital signs every 30
mts and others 60 mts during
reassessment.

Triage time

Triage

is an essential function of EDs

Urgency refers to the need for time
critical intervention.
Patients who are not critical with low
acuity categories safe to wait for
assessment and treatment but still require
admission.

The eyes dont

see what the
mind doesnt
know!

1.
2.
3.
4.
5.
6.

Rapidly identify patients with urgent life

threatening conditions
Assess/ determine severity and acuity of
the problem
Ensure that patients are treated in order of
clinical emergency
Ensure that treatment is appropriate and
timely
Allocate the patients appropriate and
treatment area
Reevaluate who are in waiting area

Goals of triage

1.
2.
3.
4.
5.
6.

Streamlines patient flow

Reduces risk of further injury/
deterioration
Improves communication and public
relations
Enhances team work
Identifies resource requirements
Establishes national benchmarks

Advantages of triage

 The

triage team

Triage

of Victims
- first victims to arrive are frequently not
the most seriously injured. They are

1. Critical patients
2. Fatally Injured Patients
3. Non critical patients
4. Contaminated patients

Triage area includes

Are

divided into 5 levels or categories

depending on following acuity
determinants

1.Chief complaint
2.Brief triage history
3.Injury/ illness
4.General appearance
5.Vital signs

The most urgent clinical feature that is

identified will determine ALS category

Triage acuity system [ATS ]

Level 1- Resuscitation
Level 2- Emergent
Level 3- urgent
Level 4- less urgent
Level 5- Non urgent

Triage acuity system or levels

Resuscitation -- threat to life

Time to nurse assessment
IMMEDIATE
Time to physician assessment IMMEDIATE
Cardiac and respiratory
Major trauma
Active seizure
Shock
Status Asthmatics

arrest

Level I Immediate :

Potential threat to life, limb or function

Nurse Immediate , Physician <10 minutes

Decreased level of consciousness

Severe respiratory distress
Chest pain with cardiac suspicion
Over dose (conscious)
Severe abdominal pain
G.I. Bleed with abnormal vital signs
Chemical exposure to eye

Level II - emergent

Condition with significant distress

Time Nurse < 15min, physician < 30 min
Head injury without decrease of LOC but
with vomiting
Mild to moderate respiratory distress
G.I. Bleed not actively bleed
Acute psychosis

Level III - Urgent

Conditions with mild to moderate discomfort

Time for Nurse assessment < 30 minutes
Time for physician assessment < 1hour
Head injury, alert, no vomiting
Chest pain, no distress, no cardiac suspicion.
Depression with no suicidal attempt

Level iV less urgent

Conditions can be delayed, no distress

Time for nurse 60 minutes
Physician assessment more than 2h or 120
minutes
Minor trauma
Sore throat with

temperature < 39 degree

centigrade
Chronic medical illnesses.
Alcoholics

Level v non urgent

An

across-the room assessment

The

triage history

The

triage physical assessment

The

triage decision

Basic components of triage

An across the room assessment

To identify obvious life threat conditions
General appearance

Disability
(neurogenic)
Air way

Circulation
Breathing

The triage nurse must scan the area

where patients enter the emergency door,
even while interviewing other patient.

Across the door assessment

Air

way
Abnormal airway sounds, strider, wheezing
grunting
Unusual posture e.g.. Sniffing position, inability
to speak, drooling or inability to handle
secretion
Breathing
Altered skin signs, cyanosis, dusky skin,
tachypnea
bradypnea, or apnea periods, retractions, use
accessory muscles, nasal flaring, grunting, or
audible wheezes

Across the room assessment

Circulation

Altered skin signs, pale, mottling, flushing

Un controlled bleeding
Disability

(neuro.)

LOC
Interaction with environment
Inability to recognize family members
Unusual irritability
Response to pain or stimuli
Flaccid or hyper active muscle tone

Across the room assessment

Extensive

treatment

knowledge to emergency medical

Adequate

training and competent skills,

language, terminology

Ability
Good

to use the critical thinker process

decision maker

Triage Nurse should have

 Greet patients and identify your self.

Maintain privacy and confidentiality
Visualize all incoming patients even while

interviewing

others.
Maintain good communication between triage and
treatment area
maintain excellent communication with waiting area.
Use all resources to maintain high standard of care.
Crowd control.
Telephone.
Communicate with team leader and seek feed back on
decisions.

duty of a triage nurse

Reassess

the patient within 1-2hours of

initial triage and continue to reassess on a
regular basis, patients who may have
presented without cardinal signs of severe
illness may develop them during long
waits.
Patients who appear intoxicated actually
may have life threatening problems such
as DKA, and should not be permitted to
keep it off in the waiting room.

retriage

The

last person in along line at triage may

have a serious medical problem that
requires immediate attention

Patient

should wait no longer than 10

minutes for triage

If

in doubt about a category, choose the

higher acuity to avoid under triaging a
patient

Key points

With

a trauma call involving a pregnant

patient, you have two patients:
The woman
The unborn fetus

Any

trauma to the woman has a direct

effect on the fetus.

Special Considerations for

Trauma and Pregnancy

Pregnant

women may be the victims of:

Assaults
Motor vehicle crashes
Shootings
Domestic abuse
Pregnant

women also have an increased

risk of falls.

Special Considerations for

Trauma and Pregnancy

Pregnant

women have an increased

amount of overall total blood volume and
a 20% increase in heart rate.
May have a significant amount of blood loss
before you will see signs of shock
Uterus is vulnerable to penetrating trauma
and blunt injuries.

Special Considerations for

Trauma and Pregnancy

When

a pregnant woman is involved in a

motor vehicle crash, severe hemorrhage
may occur from injuries to the pregnant
uterus.
Trauma is one of the leading causes of
abruptio placenta.
Significant vaginal bleeding is common with
severe abdominal pain.

Special Considerations for

Trauma and Pregnancy

Cardiac

arrest

Focus is the same as with other patients.

Perform CPR and provide transport.
Notify the receiving facility personnel that
you are en route with a pregnant trauma
patient in cardiac arrest.

Special Considerations for

Trauma and Pregnancy

Follow

these guidelines when treating a

pregnant trauma patient:
Maintain an open airway.
Administer high-flow oxygen.
Ensure adequate ventilation.
Assess circulation.
Transport the patient on her left side.

Special Considerations for

Trauma and Pregnancy

Some

cultures may not permit a male

health care provider to assess or
examine a female patient.
Respect these differences and honor
requests from the patient.
A competent, rational adult has the right to
refuse all or any part of your assessment or
care.

Cultural Value Considerations

The

Golden Period is the time from

injury to definitive care.
Treatment of shock and traumatic injuries
should occur.
Aim to assess, stabilize, package, and begin
transport within 10 minutes (Platinum
10).

Determine Priority of Patient

Care and Transport

Determine Priority of Patient

Care and Transport

Rapid

scan assists in determining

transport priority.

High-priority

patients include those with

any of the following conditions:
Difficulty breathing
Poor general impression
Unresponsive with no gag or cough reflex

Determine Priority of Patient

Care and Transport

High-priority

patients (contd):

Severe chest pain

Pale skin or other signs of poor perfusion
Complicated childbirth
Uncontrolled bleeding

Determine Priority of Patient

Care and Transport

High-priority

patients (contd):

Responsive but unable to follow commands

Severe pain in any area of the body
Inability to move any part of the body

Determine Priority of Patient

Care and Transport

Transport

decisions should be made at

this point, based on:
Patients condition
Availability of advanced care
Distance of transport

Determine Priority of Patient

Care and Transport

Transport

decision

Provide rapid transport for pregnant

patients who:
Have significant bleeding and pain
Are hypertensive
Are having a seizure
Have an altered mental status

Primary Assessment

Circulation

If there are signs of shock, control bleeding,

give oxygen, and keep the patient warm.
Transport

decision

If delivery is imminent, prepare to deliver at

the scene.
If delivery is not imminent, prepare the
patient for transport.

Primary Assessment at
accident area

originated

in WW I by French
doctors treating the battlefield wounded at
the aid stations behind the front
3 categories
Those who are likely to live, regardless of what
care they receive
Those who are likely to die, regardless of what
care they receive
Those for whom immediate care might make a
positive difference in outcome

simplest

term: the sorting or prioritizing

of items
Concepts

1) Utility
2) Relevance
3) Validity
1

operational objectives: time to see

physician

"usual

presentation"

not totally dictated by the presenting complaint

vital

signs, PEFR, O2 saturation, pain

scales

Assigning Triage

A.
B.
C.
D.
E.

F.

To rapidly identify patients with urgent, life

threatening conditions.
To determine the most appropriate treatment
area for patients presenting to the ED.
To decrease congestion in emergency treatment
areas.
To provide ongoing assessment of patients.
To provide information to patients and families
regarding services expected care and waiting
times.
To contribute information that helps to define
departmental acuity.

Goals of Triage

The

triage nurse should have rapid access

or be in view of the registration and
waiting areas at all times.

Role of Triage Personnel

1.
2.
3.
4.
5.
6.

7.
8.
9.

Greets client and family in a warm empathetic manner.

Performs brief visual assessments.
Documents the assessment.
Triages clients into priority groups using appropriate
guidelines.
Transports client to treatment area when necessary.
Gives report to the treatment nurse or emergency
physician, documents who report was given to and
returns to the triage area.
Keeps patients/families aware of delays.
Reassesses waiting clients as necessary.
Instructs clients to notify triage nurse of any change in
condition.

Role of Triage Personnel

Accurate:

based on

Practical knowledge gained through experience

and training.
Correct identification of signs or symptoms.
Use of guidelines and triage protocols.
recorded

on all patients, during all shifts

Role of Triage Personnel

 dynamic

process

A patients condition may improve OR deteriorate

during the wait for entry to the treatment area.

Triage

Process: Primary survey vs Primary

Nursing Assessment
The need to meet time objectives for triage
assignment within 10 minutes of arrival means
that the triage assessment may be limited to 2
minutes unless there are other operational
policies like bringing on more triage personnel.

General Triage Guidelines

1.
2.
3.
4.

Chief complaint
Subjective
Objective
Additional Information:
Allergies
Medications

The triage assessment

Objectives

for time to Nursing

reassessment is related to triage level
exceeded the time objective: up triaged

Reassessment

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Date and time of triage assessment.

Nurses name.
Chief complaint or presenting concerns.
Limited subjective history: onset of injury/symptoms
Objective observation.
Triage Level
Location in the department.
Report to treatment nurse.
Allergies
Medications
Diagnostic, first aid measures, therapeutic interventions.
Reassessment(s).

Documentation Standards

Triage & Acuity Scale Category

Definitions

Conditions

that are threats to life or limb

(or imminent risk of deterioration)
requiring immediate aggressive
interventions.

Level I Resuscitation

Conditions

that are a potential threat to

life limb or function, requiring rapid
medical intervention or delegated acts.

Level II Emergent

Level II Emergent

Conditions

that could potentially progress

to a serious problem requiring emergency
intervention.

Level III Urgent

Conditions

that related to patient age,

distress, or potential for deterioration or
complications would benefit from
intervention or reassurance within 1-2
hours.

Level IV Less Urgent

(Semi urgent)

Conditions

that may be acute but nonurgent as well as conditions which may be

part of a chronic problem with or without
evidence of deterioration.

Level V Non Urgent

INTRODUCTION

INTRODUCTION

Malaysia is located in South East Asia

in

Bordered by Thailand in the north and Singapore

the south

group

Consists of 15 states and has a democratic

government
Comprises of multi-ethnic groups, the Malay
being the majority (70%) and others such as
Chinese and Indians

The land area is 330,252 square kilometers with

population of just over 25 million

INTRODUCTION

Life expectancy at birth in 2008 for males was

70.3 years and for females, 75.2 years

The health facilities are provided by the Ministry

of Health (MOH), Ministry of Education
(university
hospitals), and private sectors

Each of the 15 states are provided with a General

Hospital that perform as referral center

INTRODUCTION

Total number of doctors of 17 442

The ratio of doctors to population as in 2002 is 1 to 1

474

MOH allocation to National Budget is 6.33%,

amounting
to Malaysian Ringgit (RM) 5 765 553 410

80% of which was for the operating budget and the

other 20% for the development budget

INTRODUCTION
1

Normal Delivery

14.91%

Complications of Pregnancy

12.39%

Accident

9.11%

Diseases of the Respiratory Systems

7.30%

Diseases of the Circulatory Systems

7.26%

Perinatal Conditions

6.57%

Diseases of the Digestive Systems

5.20%

Diseases of the Urinary Systems

3.74%

Ill-defined Conditions Diseases

3.43%

10

Malignant Neoplasms

3.13%

Total admission = 1,905,689

Figures from Ministry of Health Malaysia 2007

INTRODUCTION
Principal Causes of Deaths In Government Hospitals Malaysia in 2007
1

Septicemia

16.87%

Heart Diseases & Diseases of Pulmonary Circulation

15.70%

Malignant Neoplasm

10.59%

Cerebrovascular Diseases

8.49%

Pneumonia

5.81%

Accident

5.59%

Diseases of Digestive System

4.47%

Perinatal Conditions

4.20%

Kidney Diseases

3.83%

10

Ill-Defined Conditions

3.03%

Total death = 49, 586

Figures from Ministry of Health Malaysia 2007

Motor Vehicle Crash & Type of Injuries

Motor vehicle
Crash

2002

2003

2004

2005

2006

2007

2008
Jan-Jun

Death

5,378

5,634

5,678

5,623

5719

5672

3,018

Serious Injuries

6,696

7,163

7,444

7,600

7373

7384

3,632

Mild Injuries

30,259

31,357

33,147

25,905

15596

13979

6,690

Mechanical
Damage

237,378

254,499

280,546

289,136

312564

336284

170,357

Total Case

279,711

298,653

326,815

328,264

341,252

363,319

183,357

Data from Royal Police Force Malaysia 2008

INTRODUCTION
10 year statistic on Road Traffic Accident
Year

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Total Injuries

55,693

53,063

50,20
0

50,50
6

47,82
3

50,864

47,080

39,71
6

29,258

27,64
5

Minor injuries

37,885

36,886

34,37
5

35,97
3

35,23
6

37,415

33,413

25,92
8

15,596

13,97
9

Major injuries

12,068

10,383

9,790

8,684

6,696

7,163

7,444

7,600

7,375

7,384

Total Death

5,740

5,794

6,035

5,849

5,891

6,286

6,223

6,188

6,287

6,282

Death Index
(10,000 registered
vehicles)

6.28

5.83

5.69

5.17

4.9

4.9

4.52

4.18

3.98

3.7

Accident Index
(10,000 registered
vehicles)

230.9

224.7

236.3

234.6

232.7

233

237.4

220.6

216.1

216.1

Major injuries & Total injuries REDUCING TREND BUT..

TOTAL DEATH UNCHANGED !!!!
(Data from: safety & road dept. Malaysia 2009)
http://www.jkjr.gov.my/

Historically
Historically EMS in Malaysia was very
underdeveloped prior to 1998

It was the most neglected clinical part of the

hospital & health system for many years

The services was staffed by orthopedists,

general
surgeons or generalists such as senior medical
officers

Understaffed and patients are poorly managed

It was a place for dumping those medical staff

with attitude problems or without career planning

Pre hospital & In Hospital EMS:

Infrastructure
Equipment upgrading
Staff training/allocation

At Present.

Subspecialty areas
New ambulances
New Guidelines/protocol
Empowerment for EM physicians
Recognition (14th specialty)

Training:
More universities for EM
postgraduate program
- Conjoint program/exam board
Now total EPs are 55 (Min 1 EP per state)
Paramedic training increased
Public training/education life support

ORGANIZATION Operating system

In general prehospital care is still

underdeveloped

Emergency medicine has just passed

the infancy phase

Anglo American model

Government & NGOs service

provision by:
- Hospital/Health
- Civil Defence
- Fire & rescue services

ORGANIZATION Operating system

Land ambulances
- Government (MOH, University Hospitals, Civil Defense)
- NGOs (St Johns, Red Crescent, Private organization)
- Hospital based (General Hospital, University Hospitals, District)
- Hospital receives ambulance call
- Also utilized for inter facility transfers (district to tertiary centers)

ORGANIZATION Operating system

Air & water ambulances
- For rural areas (East Malaysia, borneo)
- Austere environment
- Mainly governmental services

RM 5.1 Million (USD 1.4 Million for operating flying do

STANDARDS
i.

Vehicles (staff & equipment)

ii.

Manpower (training/certification)

iii.

Response time (dispatch)

iv.

Call center

v.

Medical Control

vi.

Funding

Vehicles (staff & equipment)

Old Days !!!!

Manned by non
paramedics
Ambulance driver
with nursing staff
Minimally trained &
equipped
Scoop & Run Concept

Vehicles (staff & equipment)

Better equipped
Trained nursing staff
Accompanied by doc

Manpower (training/certification)
Level of care:

- Depends on the operators i.e MOH or private sectors

- Manned by ambulance driver basic paramedic/murses - doctors
- Levels of training varies and not standardized certification progra
- No legislation formatted
- Care level ranges from first aid first responder basic life suppo
- Occasionally doctors accompanying seriously ill patients
- No EMT program
- Recently variety of organization have implemented training progr

Nurses/Medical Assistants basic life/trauma support/first aid

Civil Defense - basic life/trauma support/first aid/first responder
Police First responder program

Manpower (training/certification)
Examples of effort by certain organization:
i. Hospital Universiti sains Malaysia

EMD program
Involve ambulance drivers and other support staff (BLS, BTLS, Fir
ii. Civil Defense
iii. St Johns Ambulance
iv. UKM Medical Center
v. Ministry of Health

Response time (dispatch)

Ambulance Response Time (ART) Before and After Emergency Medical Dispatcher
(EMD) Training Program (Statistics January Till December 2004 from Call Center
Hospital Universiti Sains Malaysia)

GROUP

Call Processing
Time (CPT)

Time Taken to
Prepare Team
(TTP)

Time Taken To Arrive

At Scene
(TTTS)

Ambulance
Response Time
(ART)

Without EMD
Mean
Number of Calls
Std Deviation

117.00
1000
54.93

203.91
1000
115.24

1325.29
1000
1572.30

1646.21
1000
1609.39

With EMD
Mean
Number of Calls
Std Deviation

117.67
1000
55.20

117.00
1000
54.93

676.83
1000
1451.08

911.50
1000
399.34

Mean Time in seconds

P=0.002
ART = CPT + TTP + TTTS

Response time (dispatch)

Mean Ambulance Response Time At

Tertiary Hospitals In Three Different
Cities in Malaysia
Cities

Mean Call
Processing
Time (CPT)

Mean Time
Taken to
Prepare
Team
(TTP)

Mean Time
Taken To
Arrive At
Scene
(TTTS)

Mean
Ambulance
Response
Time (ART)

Kota Bharu

117.67

117.00

676.83

911.50

Penang

154.07

218.56

896.33

1268.96

Kuala
Lumpur

135.48

196.22

1208.08

1539.78

Mean Time in seconds

P<0.05

Malaysia Emergeny Response System

OLD DAYS.
i. 999
ii. 994
iii. 991
iv. 112
services

Police
Fire & Rescue
Civil defence
Mobile phone

Public got CONFUSED!!!!!

Lack of Coordination!!!!!
Miscommunication!!!!!
Technical difficulties!!!!!
Multitasking effort!!!!!

Malaysia Emergeny Response System

Major step
June 2007

Malaysia Emergeny Response System

i.

One number Client focus (response to 999 calls within 10 sec or 4 rings)

ii. Automatic routing system with zero defect

iii. Standardization of client interaction protocol for all call centers
iv. Single Communication network for all agencies involved
v. Online incident management protocol before arrival of response team
vi. Trained EMD at call center

Malaysia Emergeny Response System

Call center Hospital based

Malaysia Emergeny Response System

Ambulance call form

Ambulance calls 2008 civil defense

Technical fault (6.20%)

Prank calls (8.07%)

False calls (0.51%)

True calls (82.6%)

Malaysia Emergeny Response System

- Civil Defense 2008 Statistic

Total Cases
Percentage

1
2
3
4

1
915
9
36.1
9

2
16
10 12
0.63

Motor vehicle crash

Injury at workplace
Commit suicide
- Assault

0.4
7

5
6
7
8

3
30
1.1
9

4
1,153
Total
45.61

78

58

258

0.24

0.08

3.0
9

2.2
9

10.2
1

Medical/surgical causes
Trapped
Submersion injury/drowning
Wild reptile (snakes)

8
2,477

9 Bee/Hornet
10 - Others

Mass
Casualty
Incidence

J
A
N
U
A
R
Y

F
E
B
R
U
A
R
Y

M
A
R
C
H

A
P
J J
R M U U
I A N L
L Y E Y

S
E
A P
U T
E
G M
U B
S E
T R

O
C
T T
O
O TA
B L
E
R

Flooding

23

Collapsestructure

Fire

MaritimeIncidence

SAR

Industrialaccident

Landslide

Aircrash

Typhoon

11

35

Jumlah

January - Dicember 2008

Pre Hospital Delivery of Care

i. Hospital ambulance based (MOH, University Hosp, Private Hosp.)

Receive calls at call center based in the emergency department
Dispatch ambulance to the site
Minimal intervention scoop and run vs. stay and play
Bring the patient back to the base emergency dept
Facilities varies
Interfacility transport
From district hosp to tertiary centers or vice versa
Manned by nurses
Basic facilities
ii. Private Operator (St Johns, Red Crescent)
Receive call at their own call center out of hospital

Pre Hospital Delivery of Care

Stay & Play Concept

Acute hospital care

In the past time.
Time ?
Transportation problems

No doctors

Health Centers

District hospital

Small ED
Limited no of
doctors

Time ?

OUTCOME
POOR

Tertiary

Equipped
Hospital ED
Emergency
Physicians

Beyond the Golden / Platinum Hours : SURVIVAL POOR

Acute hospital care

In the present time..
Doctors/MA present

Health Center
District hospital

Transportation Time
Communication Time
REDUCED

Tertiary Hospitals

Emergency Medicine developing

Better equipped ED
Better transportation

Standard Resuscitation Bay in Emergency Dept

Medical Control

i. Ambulance services in MOH/Univer Hosp are under the control of

Emergency Dept Headed by Emergency Physicians
ii. Protocols and guidelines guided by EPs
iii. Minimum One EP per state or per University Hosp
iii. Training/Credentialling of ambulance staff is controlled by local dep
iv. Mostly Off line medical control, on line via walkie talkie/hand phon
v. Idea to privatise the service has been put forward many obstacles!!
i. Private operators No Emergency Physicians
ii. Own protocol/guidelines
iii. Medical direction off line/online
iv. Credentialling ?????
v. Headed by senior staff members

Funding

MOH allocation to National Budget is 6.33%,

amounting to Malaysian Ringgit (RM) 5 765 553 410

Government Hospitals allocation of budget to the

Emergency dept

Budget for vehicles come from state health office

Equipment budget from the dept.

Priority for Emergency services is less

More focus on

RESEARCH
Very limited
Few research conducted by Trainee in Emergency Medicine
A study on the ambulance call received at the call center Hospital Universiti Sains Malaysia
Zainalabidin I, Nik Hisamuddin NAR, Rashidi A, Mohd Shaharuddin S. May 2007
High percentage of misuse (mostly prank calls) of the emergency hotline. Half of the ambulance
Calls were associated woth communication difficulties
Pattern of injury & preventability of prehospital death among motorcyclist
Noor Azleen A, Wan Aasim WA, Rashidi A, Nik Hisamuddin NAR. May 2006
Based on ISS, 67% had ISS > 50, 31% had ISS of 75. 36% of them died before reaching
Hospitals. 39% died in the Emerg dept.

RESEARCH
Interhospital ambulance transportation of critically patients to Kuala Lumpur Hospital
Ridzuan MI, Abu Hassan A, Wan Aasim WA, Kamaruddin J, Rashidi A,
Nik Hisamuddin NAR. May 2003
58% were trauma cases, 68% referral from district hospitals & health centers. 51% seriouslyill patient
were accompanied by junior doctors only trained at the level of BLS. 47% of ambulance equipped
with two way radio communications
Ambulance call response interval in Kuala Lumpur Malaysia
Khairi K, Abu Hassan A, Kamaruddin J, Wan Aasim WA. May 2003
The ambulance call response interval was 15.1 + 8.4 minutes. The causes of delay include traffic jam,
wrong address, wrong route taken, tall building.

PERFORMANCE INDICATOR
i. Ambulance response time
ii. Call processing time
iii. Crew mobilizing time
iv. Client feedback/satisfaction

Poor

Excellent

Vehicle appearance
1. General appearance of the ambulance
2. Cleanliness of ambulance
3. Comfort of ride in the ambulance
4. Feeling of security in the ambulance
5. Adequacy of ambulance equipments

1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10

Staff attitude
6. Helpfulness of staff
7. Attentiveness of staff
8. Empathy nature of staff
9. Friendliness of staff
10. Gentleness of staff

1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10

Staff performance
11. Ensuring of patients comfort
12. Calmness of staffs
13. Adequacy of explanation by staff of their actions
14. Efficiency of staff
15. Feeling of safety when staff arrive

1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10

Professionalism
16. Perceived level of training of staff
17. Professional look of staff
18. Level of trust in staff
19. Level of competency of staff
20. Confidence of staff to keep me alive until reaching hospital

1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10

Efficiency of service 21. Availability of staff at all times

1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10

22. Response time of ambulance to an emergency

23. Speed of admittance to hospital

Image
24. What do you think is the public perception of our ambulance service?

1 2 3 4 5 6 7 8 9 10

PRESENT & FUTURE CHALLENGES

i. Multiple providers
ii. Non standard training program/certification
iii. Poorly or untrained EMS staff
iv. Poor public comprehension about EMS
v. Non uniformity of allocation in services
vi. Poorly equipped ambulances
vii.Poor quality ambulances
viii.Lack of EMS research and quality control
ix. Privatizing the service ???

Terima kasih
Ass Wr Wb