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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
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Country InformationRegional Map Showing:
Singapore
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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.
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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
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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.
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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
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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%
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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SINGAPORE GENERAL SINGAPORE GENERAL HOSPITALHOSPITAL
An OverviewAn Overview
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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
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Facilities
ServiceService
No. of beds 1,389
No. of clinics 169
No. of procedure rooms 26
Operating theatre suites 47
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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
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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
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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
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Department of Emergency Medicine
• 9 Senior Consultants / Consultants
• 7 Associate Consultants / Registrars
• Medical Officers on rotation
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Department of Emergency Medicine
Other services
• Drug and Poison Information Center
• Emergency Medicine Research
• Maritime Radiomedical Service
• Life Support Training Center
• Emergency Preparedness
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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)
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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
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SCDF Annual Report 2005
Yearly volume of
SCDF Ambulance
Calls
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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
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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%
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SCDF Annual Report 2005
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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
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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
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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
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Pre-Hospital Emergency Care Dispatch Mechanism
No. to Call:
• EMS + Fire Brigade 995
• Police 999
• Non Emergency Ambulance 1777
• SARS Ambulance 933
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Control RoomCaller
Incident Site
Hospital
Fire Stn
DESPATCH SYSTEM: DESPATCH SYSTEM: AMBULANCEAMBULANCE
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Emergency Medical Dispatch
• Caller ID• Automatic location tracing (address database)• Computer assisted dispatch and ambulance
monitoring• GPS navigation and location tracking• Emergency Medical Dispatchers
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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)
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Updates in Prehospital Care
Systems Status Management
Response Time Reliability Unit Hour CostsProductivityDemand AnalysisSystem Status Plan
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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.
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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.
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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)
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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
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Early defibrillation
• Most important intervention affecting mortality
• Advent of the Automated External Defibrillator
•Easy to use•Step by step instructions•Voice prompts
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1995: First Five Years of Pre-Hospital Automatic Defibrillation Project in Singapore
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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
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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)
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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)
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Early basic andadvanced careOxygenAirway adjunctsImmobilise fractures and spinal injuriesIV fluidsTamponade bleedingLaryngeal mask airwayAsprin (Oral)SalbutamolDextroseGTNAdrenaline (intravenous)OxytocinDiazepam for seizures
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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
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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.
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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.
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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.
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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.
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What would it take to improve EMS in Asia?
Champions and Advocates for EMS!
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Organised by:
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Conference Secretariat:
Tel: (65) 6 379 5261/ 6 379 5259Fax: (65) 6 475 2077 Email: [email protected]
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Visit our website :
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See You in Singapore!