Ems In Singapore

mergency Medical mergency Medical Services inServices in

INGAPOREINGAPOREA/Prof Marcus Ong

Consultant, Senior Medical Scientist& Director of Research

Department of Emergency MedicineSingapore General HospitalAdjunct Associate Professor

Duke-NUS Graduate Medical SchoolOffice of Research

Country InformationRegional Map Showing:

Singapore

History of Singapore

1300 2000190018001700160015001400

14th century: Singapore was a fishing village known as Temasek or Sea Town.

End of 14th century, the Sanskrit name, Singapura (Lion City), become commonly used.

History of Singapore

1300 2000190018001700160015001400

29 January 1819, Stamford Raffles landed on Singapore

6 February 1819, formal treaty concluded with the Sultan Hussein of Johor and the Temenggong

History of Singapore

1300 2000190018001700160015001400

Malaysia formed on 16 September 1963, and consisted of the Federation of Malaya, Singapore, Sarawak and North Borneo (now Sabah).

Singapore separated from Malaysia on 9 August 1965, and became a sovereign, democratic and independent nation.

Admitted to the United Nations on 21 September 1965, member of the Common Wealth of Nations on 15 October 1695. On 22 December 1965, it became a republic.

Facts of Singapore• Area - 648 km2

• Population - 4.1 million

• Ethnic groups– Chinese 76.5%– Malay 13.8%– Indian 8.1%– Others 1.6%

www.singstat.gov.sg, June 2002

Percentage of Singapore Resident Population

Age Group Percentage (%)0 - 4 6.18

5 - 14 15.0115 - 24 12.6325 - 34 16.3835 - 44 19.0545 - 54 15.3455 - 64 7.9265 - 74 4.79

75 & over 2.70Total 100.00

www.singstat.gov.sg, June 2002

7.5%

Socio - EconomicsSingapore GDP per capita in comparison with other nations

Nation GDP-PPP per capita (to nearest thousand)

United States $36,000Norway

SwitzerlandAustriaBelgiumDenmark

Hong KongIcelandJapanJersey

SingaporeCIA World Factbook, July 1, 2002

$28,000

$25,000

• National Health Care Expenditure (Singapore) - 2.8% of GDP

• National Health Care Expenditure (US) - 13.9% of GDP in 2001

Burden of Disease• Life Expectancy

– 78.7 years

• Top 5 leading Causes of Residential Death– Cancer (28.0%)– Ischaemic & Other Heart Diseases (24.2%)– Pneumonia (13.1%)– Cerebrovascular Disease (8.8%)– Injuries (6.7%)

MOH Statistics - Health Facts Singapore 2003

Health Status of Singapore- good by International

Standards• Boost Health of Singapore

– Rising Standards of Living– High Standards of Education– Good Housing– Safe Water Supply and Sanitation– High Level of Medical Services– Active Promotion of Preventive Medicine

http://app.moh.gov.sg/our/our01.asp

Healthcare Delivery System

Dual System of Health Care Public system run by the

Government Private system provided by Private

Practitioners Subsidised medical care at public

hospitals and polyclinics

Healthcare Delivery System

Public PrivatePrimary Healthcare Outpatient Polyclinic

(20%)Average consultation fee

S$10 - S$15

General Practitioners(80%)

Average consultation feeS$25

Secondary / Tertiary Specialist Care

Restructured Hospital(80%)

Private Hospital(20%)

US$ 1 = S$1.75

Euro $1 = S$1.96

Hospital No. of Beds ED AttendenceAH 389 43,402

CGH 801 124,188KKH 888 94,904NUH 946 88,545SGH 1509 114,827TTSH 1163 131,127

January - December 2002

Healthcare Delivery System

Bed to population ratio : 3.6 beds per 1000 population

Healthcare Delivery System

Individual Responsibility- Medisave Account

- 6 - 8% income by law

- for hospitalization expenses for individual or family members

- MediShield- Catastrophic insurance

scheme

- Help meeting medical expanses from major to prolong illness

Government Subsidy- Lower classes of wards

in public hospital are subsidized up to 80% by Government

- Medifund- Endowment fund set up

by government to help indigent pay for their medical care

Hospitalisation Co-payment

Medical Education

• One Medical School for Undergraduate Program– National University of Singapore (NUS)

• Length of Study– 5 years + 1 year of house officer (Intern)

• In 1984, Emergency Medicine was recognized as a distinct medical specialty by the Ministry of Health

Postgraduate Training Program - 1989

• Structured Basic Postgraduate Training Program in Emergency Medicine (Residency) - 3 years– 1 year Accident and Emergency Medicine posting

– 1 year Acute Surgery posting (suggested 6 months general surgery, 3 months orthopaedic)

– 1 year Acute Medical posting (suggested 6 months general medicine, 3 months cardiology, 3 months paediatrics)

MRCS Edin (A&E) M Med (Emerg Med)

Postgraduate Training Program - 1991

• Advance Postgraduate Training Program - 3 years• Seven Areas of Sub-Specialization

– Emergency Cardiac Care

– Emergency Trauma Care

– Emergency Toxicology

– Pre-hospital Emergency Care

– Paediatric Emergency Medicine

– Disaster Medicine

– Observation Medicine Exit Interview with 3 member board of assessors

Ministry of Medicine (MOH)

Singapore Medical Council

Specialist Accreditation Board

Joint Committee or Specialist Training (35 STC)

MRCP M MED (Int Med)Cardiology

Dermatology

Endocinology

Gastroenterology

Geriatric Medicine

Haematology

Infectious Diseases

Internal Medicine

Medical Oncology

Neurology

Renal Medicine

Respiratory Medicine

Rheumatology

MRCS M MED (Surgery)Cardiothoracic Surgery

General Surgery

Hand Surgery

Neurosurgery

Orthopaedic Surgery

Paediatric Surgery

Plastic Surgery

Urology

Anaesthesiology

Diagnostic Radiology

Emergency Medicine

Nuclear Medicine

Obstetrics Gynaecology

Occupational Med

Ophthalmology

Otorhinolaryngology

Paediatric Medicine

Pathology

Psychiatry

Public Health Med

Rehabilitation Med

Therapeutic Radiology

SINGAPORE GENERAL SINGAPORE GENERAL HOSPITALHOSPITAL

An OverviewAn Overview

186 Years of HistorySixth General Hospital opens at Sepoy Lines

29 March 192629 March 1926 Opening of SGH, the Opening of SGH, the seventh in line of seventh in line of general hospitals. general hospitals.

12 September 12 September 19811981 Opening of a new and Opening of a new and rebuilt SGH.rebuilt SGH.

18211821The First General

Hospital is located at the cantonment for troops at Stamford

Road

18818822

Facilities

ServiceService

No. of beds 1,389

No. of clinics 169

No. of procedure rooms 26

Operating theatre suites 47

31 Clinical Specialties

Diagnostic RadiologyDiagnostic Radiology

Emergency MedicineEmergency Medicine

Nuclear Medicine Nuclear Medicine

PathologyPathology

Therapeutic Radiology Therapeutic Radiology (NCC)(NCC)

DermatologyDermatology

EndocrinologyEndocrinology

GastroenterologyGastroenterology

HaematologyHaematology

Internal MedicineInternal Medicine

NeonatologyNeonatology

Psychiatry & BehaviouralPsychiatry & Behavioural MedicineMedicine

Rehabilitation Medicine Rehabilitation Medicine

Renal MedicineRenal Medicine

Respiratory & Critical Respiratory & Critical Care MedicineCare MedicineRheumatologyRheumatology

Cardiology (NHC)Cardiology (NHC)

Medical Oncology (NCC)Medical Oncology (NCC)

Anaesthesia & Surgical Anaesthesia & Surgical Intensive CareIntensive Care

Colorectal SurgeryColorectal Surgery

General SurgeryGeneral Surgery

Hand SurgeryHand Surgery

Obstetrics & GynaecologyObstetrics & Gynaecology

Orthopaedic SurgeryOrthopaedic Surgery

OtolaryngologyOtolaryngology

Plastic Surgery / BurnsPlastic Surgery / Burns

UrologyUrology

Ophthalmology (SNEC)Ophthalmology (SNEC)

Cardiothoracic Surgery Cardiothoracic Surgery (NHC)(NHC)

MedicalMedicalSurgicaSurgica

ll Ambulatory &Ambulatory &

Clinical Clinical Support Support

ServicesServices

ResearchResearch

Neurology (NNI)Neurology (NNI)

Neurosurgery (NNI)Neurosurgery (NNI)

Clinical ResearchClinical Research

Clinical Trials & Clinical Trials & Resource VenturesResource Ventures

Experimental SurgeryExperimental Surgery

Hospital Statistics (2001)

SGHSGH NHC NHC NCC NCC TotalTotal

AdmissionsAdmissions NumberNumber 64,40564,405 9,2249,224 3,7253,725

77,35477,354%% 83 83 11 11 5 5 100 100

Outpatient Outpatient AttendanceAttendance 594,076594,076 73,97373,973 99,73599,735

767,784767,784%% 77 77 10 10 13 13 100 100

A&E AttendanceA&E Attendance 112,713112,713 - - - -112,713112,713

Department of Emergency Medicine

• 24 hour Accident and Emergency center

• Manage all types of medical, surgical, trauma, obstetric/gynecology, paediatric etc emergencies

• 24 bedded Emergency Observation Ward

Department of Emergency Medicine

• 9 Senior Consultants / Consultants

• 7 Associate Consultants / Registrars

• Medical Officers on rotation

Department of Emergency Medicine

Other services

• Drug and Poison Information Center

• Emergency Medicine Research

• Maritime Radiomedical Service

• Life Support Training Center

• Emergency Preparedness

Local Emergency Medical Local Emergency Medical

Services (EMS) SystemServices (EMS) SystemRun by the Singapore Civil Defence Force

Currently operating 36 ambulances in 14 stations and 10 satellite stations

Single tier system

Able to provide BCLS and defibrillation using Automated External Defibrillators (AEDs)

Ministry of Home Affairs (Home Team)

Singapore Police Force

Central Narcotics Bureau

Internal Security DepartmentSingapore Civil Defence Force

Commercial and Industrial Security Corporation

Singapore Corporation of Rehabilitative Enterprises

Prisons Department

Immigration & Checkpoints Authority

Emergency Ambulance Services

SCDF Annual Report 2005

Yearly volume of

SCDF Ambulance

Calls

EAS Calls Received (Jan- Dec 2006)

Emergency calls

91%

False Alarms

3%Non- Emergency

Calls6%

Total Emergency Ambulance Service (EAS) Calls

TYPE OF CALLS 2005 2006 Absolute Change

Emergency calls 79,895 87,679 + 7784

Non- Emergency Calls 6,046 5,462 - 584

False Alarms 2,722 2,865 + 143

Total 88,663 96,006 + 7343

Table 1: Number and Types of Ambulance Calls

Types of EAS Cases (Jan- Dec 2006)

Medical

Trauma

Others

Total Emergency Ambulance Service (EAS) Calls

DESCRIPTION 2005 2006 Absolute Change

Medical 54,130 61,221.00 + 7, 091

Trauma 25,534 26,143.00 + 609

Others 231 315.00 + 84

Total 79,895 87,679 + 7, 784

Table 2: Breakdown of Emergency Ambulance Calls

0.4%

29.8%

69.8%

SCDF Annual Report 2005

Emergency Medical Services

City Population No.Ambulances

No. EMSpersonnel

Ambulance/100,000population

New York 7.3 million 138 Overnight220 Daytime225 Evening

650paramedics1700 EMT

2.78

Chicago 3 million 55 550paramedics

1.83

Singapore 4 million 27 138paramedics, 77PMT

0.65

Medical Oversight

• SCDF Medical Advisory Committee (MAC)

• Indirect medical control of paramedics following strict protocols written and approved by MAC

• Audit and review of treatment and procedures

• Training and CME

• Competency and certification

Quality Medical Oversight

• Patient is the Priority• Achieves Response Time Reliability• Accomplishes Clinical Excellence

• Requires Accountability• Realizes Stakeholder Satisfaction

• Medical Oversight Relationship– Quality Improvement– Research

Pre-Hospital Emergency Care Dispatch Mechanism

No. to Call:

• EMS + Fire Brigade 995

• Police 999

• Non Emergency Ambulance 1777

• SARS Ambulance 933

Control RoomCaller

Incident Site

Hospital

Fire Stn

DESPATCH SYSTEM: DESPATCH SYSTEM: AMBULANCEAMBULANCE

Emergency Medical Dispatch

• Caller ID• Automatic location tracing (address database)• Computer assisted dispatch and ambulance

monitoring• GPS navigation and location tracking• Emergency Medical Dispatchers

Control Room Control Room

LAYOUTLAYOUT

Fire (Monitoring)

Amb 3&4 Div (Monitoring)

Amb 1&2 Div (Monitoring)

CallTakerCallTaker

Police /Trg Console

Police /Trg Console

DECAM monitoring

r

CallTakerCallTaker

CallTaker

Supervisor

CCTV (Monitoring)

Updates in Prehospital Care

Systems Status Management

Response Time Reliability Unit Hour CostsProductivityDemand AnalysisSystem Status Plan

Updates in Prehospital Care

Demand Analysis

Basic Terminology

Demand Analysis - A statistical chart showing the historical call volume for each hour of the day and day of the week.

Updates in Prehospital Care

System Status Plan

Basic Terminology System Status Plan - An algorithm for

on-line management of system deployment and redeployment of unit hours.

1 0 Day:

2 0 3 Hour Ending:

3 0 3 6

4 0 3 6 7

5 0 3 6 7 8

6 0 3 6 7 8 10

7 0 3 6 7 8 10 5

8 0 3 6 7 8 10 5 4

9 0 3 6 7 8 10 9 5 4

10 0 3 6 7 8 10 9 5 4 2

1 2 3 4 5 6 7 8 9 10

New System Status Management Posting PyramidS

YS

TE

M A

VA

ILA

BIL

ITY

LE

VE

L

POSTING PRIORITY PROBABILITY

Tuesday

3am - 4am

(Numbers correspond with posting points)

SCDF Paramedics

• Since 1996, ambulances manned by specifically trained paramedics (roughly equivalent to North American EMT-I)

• Replacing ambulance officers (nurses)

• Undergo an 18 month training including theory, hospital and ambulance attachments

• ITE Higher NITEC paramedic course 2008

Early defibrillation

• Most important intervention affecting mortality

• Advent of the Automated External Defibrillator

•Easy to use•Step by step instructions•Voice prompts

1995: First Five Years of Pre-Hospital Automatic Defibrillation Project in Singapore

Fast Response Paramedic (FRP)

One-man crew, equipped with AED

Currently 9 FRPs in service

Shown to reduce response times by an average of almost 5 minutes

Plans to position FRPs in more satellite stations

Mean Response Time

• Fast Response Paramedics:

(9 motorcycles based in 9 fire stations)

5.5 min + 2.0 (SD)

• Ambulance:10.4 min + 5.4 (SD)

Emergency Medical Services (EMS)

• ‘Single’ Tier System• 36 ambulance based in

14 fire stations and 10 satellite stations

• Ambulance UnitParamedic (1)– CPR, BTLS– Bag Valve Mask

Ventilation– Limited I/V drug, (10%

dextrose) no intubationMedic (1)Driver (1)

Early basic andadvanced careOxygenAirway adjunctsImmobilise fractures and spinal injuriesIV fluidsTamponade bleedingLaryngeal mask airwayAsprin (Oral)SalbutamolDextroseGTNAdrenaline (intravenous)OxytocinDiazepam for seizures

Pre Hospital 12 lead ECGEssence of InnovationProposed system :

SCDF ambulance does 12 lead ECG & transmits to DEM (activate standby)

On-duty Emergency Physician reviews ECG

Emergency physician activates PCI team and catherisation lab or standby for

thrombolytics

It is hypothesized that this system will significantly reduce D2B times. Positive experience of similar trials in USA/Europe

Essence of Innovation

•LifePak 12 defibrillators upgraded with cellular modem card for wireless ECG transmission •Upon receiving patient’s ECG, the DEM can standby for the ambulance arrival and allow earlier activation of PCI for eligible patients, thus decreasing D2B/D2N time.

LIFEPAK ® 12 defibrillator/monitor series

Technical and Functional Features

LifePak 12 defibrillators

- upgraded with the addition of a cellular modem card (GPRS PC card); a wireless data transmission software upgrade will also be performed.

Technical and Functional Features

Wireless ECG transmission can be sent to a receiving station (Medtronic Lifenet RS3.0), which will be hosted at SCDF’s HQ.

Technical and Functional Features

Patient’s 12-lead ECG report, vital signs, and other information transmitted to DEM, as well as alert DEM staff of such incoming information.

What would it take to improve EMS in Asia?

Champions and Advocates for EMS!

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