Prehospital Emergency Care
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Prehospital Trauma Care in Singapore Andrew Fu Wah Ho MBBS, David Chew MBChB, MRCS, Ting Hway Wong MBBCh, MPH, Yih Yng Ng MBBS, MPH, MBA, Pin Pin Pek PgDip, Swee Han Lim MBBS, Venkataraman Anantharaman MBBS & Marcus Eng Hock Ong MBBS, MPH To cite this article: Andrew Fu Wah Ho MBBS, David Chew MBChB, MRCS, Ting Hway Wong MBBCh, MPH, Yih Yng Ng MBBS, MPH, MBA, Pin Pin Pek PgDip, Swee Han Lim MBBS, Venkataraman Anantharaman MBBS & Marcus Eng Hock Ong MBBS, MPH (2015) Prehospital Trauma Care in Singapore, Prehospital Emergency Care, 19:3, 409-415, DOI: 10.3109/10903127.2014.980477 To link to this article: http://dx.doi.org/10.3109/10903127.2014.980477
Published online: 12 Dec 2014.
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INTERNATIONAL EMS
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PREHOSPITAL TRAUMA CARE IN SINGAPORE Andrew Fu Wah Ho, MBBS, David Chew, MBChB, MRCS, Ting Hway Wong, MBBCh, MPH, Yih Yng Ng, MBBS, MPH, MBA, Pin Pin Pek, PgDip, Swee Han Lim, MBBS, Venkataraman Anantharaman, MBBS, Marcus Eng Hock Ong, MBBS, MPH
INTRODUCTION
ABSTRACT Prehospital emergency care in Singapore has taken shape over almost a century. What began as a hospital-based ambulance service intended to ferry medical cases was later complemented by an ambulance service under the Singapore Fire Brigade to transport trauma cases. The two ambulance services would later combine and come under the Singapore Civil Defence Force. The development of prehospital care systems in island city–state Singapore faces unique challenges as a result of its land area and population density. This article defines aspects of prehospital trauma care in Singapore. It outlines key historical milestones and current initiatives in service, training, and research. It makes propositions for the future direction of trauma care in Singapore. The progress Singapore has made given her circumstances may serve as lessons for the future development of prehospital trauma systems in similar environments. Key words: Singapore; trauma; prehospital emergency care; emergency medical services
Care for the multiply injured patient is a global health concern. Trauma results in 10% of all deaths worldwide annually1 and exacts a large societal and economic toll on society. Accidents, poisoning and violence was the fifth principal cause of death and the leading cause of hospital admissions in Singapore in 2011,2 mirroring worldwide trends. Many injuryrelated fatalities may be prevented or have their severity reduced by adequate prehospital trauma care.3–6 The magnitude of the problem led to the convening of the Prehospital Care Meeting at the World Health Organization headquarters in Geneva in 2004, which culminated in recommendations for the development of prehospital trauma care systems.7
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Singapore is one of the smallest countries in the world with a population of 5.3 million, a land area of 276.1 square miles (715.1 square kilometers) and a population density of 20,065 persons per square mile.8 While less crowded than New York (27,779 per square mile), it is much more crowded than most North American cities, including San Francisco (17,246/sq mi), Boston (13,321/sq mi), and Philadelphia (11,234/sq mi) or Washington, DC (9,800/sq mile).9 Singapore has a gross domestic product of 295.7 billion dollars10 and a life expectancy of 82.1 years. Singapore has a mixed health-care system,11 where the public health-care system is funded through a system of compulsory savings, subsidies, and price controls.12
Singapore’s Peculiar Circumstances
Received 16 June, 2014 from Singhealth Emergency Medicine Residency Program, Singapore Health Services, Department of Emergency Medicine, Singapore General Hospital, Singapore (AFWH), Unit for Prehospital Emergency Care, Ministry of Health, Singapore (DC), Department of General Surgery, Singapore General Hospital, Singapore (THW), Medical Department, Singapore Civil Defence Force, Singapore (YYN), Department of Emergency Medicine, Singapore General Hospital, Singapore (PPP, SHL, VA, MEHO). Revision received 17 September, 2014; accepted for publication 23 September, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. We would like to thank Lam Shao Wei from Health Services Research, Division of Research, Singapore General Hospital for his advice on SCDF’s catchment policy and provision of Figure 1.
Emergency Medical Services Emergency medical services (EMS) are provided by the Singapore Civil Defence Force (SCDF). Prehospital emergency care in Singapore was characterized in a survey of emergency medical services (EMS) directors in 2013 comparing the structure, scope of services,
Address correspondence to Andrew Fu Wah Ho, c/o Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608. Tel: +65 6321 3590. Fax: +65 6226 0294. E-mail: [email protected] doi: 10.3109/10903127.2014.980477
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410 and delivery characteristics among seven Asian countries.13 SCDF operates a fleet of 46 ambulances and 15 “fast response paramedics” (FRP) on motorcycles along with 41 first response fire-bikers in a fire-based system activated by a centralized 9-9-5 dispatching system and utilizes computer-aided dispatch protocols (Tritech Software Systems, San Diego, CA, USA). Dispatchers are predominantly firefighters, but also include paramedics and dispatch nurses. They are able to give prearrival instructions for cardiopulmonary resuscitation (CPR), use of an automated external defibrillator (AED), choking, hemorrhage control, etc. Dispatch also has global positioning satellite automatic vehicle location systems and road traffic monitoring systems. Ambulances are dispatched from 15 stations and 25 fire posts. The ambulance service is staffed by salaried personnel, provided free of charge, and is publicly funded. SCDF ambulances have a crew of 3: the crew leader, who is locally called “paramedic” (equivalent to North America’s emergency medical technician (EMT)intermediate in scope of practice), the ambulance assistant/EMT (equivalent to North America’s EMTbasic), and the driver (first aider, now being upgraded to North America’s EMT-basic level). In addition, SCDF uses motorcycle-based FRP, who are trained to the same level as the ambulance paramedics. We have also recently added first-responder “fire-bikers,” who
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are motorcycle-based firefighter-EMT (basic). Motorcycles are dispatched for major trauma, including motor vehicle collisions with resulting traffic congestion, cardiac arrest, and medical emergencies that could possibly result in cardiac arrest (unconscious, breathing difficulties). Paramedics are a distinct vocation, and are not cross trained as firefighters. However, operationally they come under the command and control of the fire service. Some firefighters are now being cross-trained as basic EMTs. Ambulance treatment is protocol driven, based on indirect medical control. However, ambulance crews are able to contact hospital-based physicians for advice or ask for a hospital medical team in cases of prolonged extrication, for example. In 2009 there were 200 providers (4.0 per 100,000 population) and 0.8 ambulances per 100,000 population. SCDF uses a catchment zone policy where patients from defined geographic areas will be conveyed to the public hospital nearest to the incident location. Mean call receipt to arrival at the scene was 8 minutes, with a standard deviation of 4.8 minutes in 2006.14 A consequence of the highly urbanized setting with more than 80% of the population residing in high rise apartments is that there is often a delay between on-scene and patient contact time, related to factors such as elevators, corridors, and stairways.15 Figure 1
FIGURE 1. Singapore Civil Defence Force catchment zones and travel time coverage.
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FIGURE 2. Annual ambulance call volume of the Singapore Civil Defence Force from 2007 to 2012.
shows the catchment zones of SCDF and the average travel time coverage of each zone in 2011. SCDF responded to 150,155 calls between January and December 2013, of which 96.1% were classified as emergency calls.16 Of these, 7.6% were road traffic accidents and 18.3% were trauma cases related to industrial accidents, falls, and assaults. SCDF annual reports indicate that there is a steady increase since 1998 in both call volume and proportion of calls classified as emergency calls. Conveyance rate was 99.9% in 2006.14 Figures 2 and 3 show the annual ambulance call volume and proportion of the types of calls the SCDF responded to between 2007 and 2012. SCDF undertook 117,896 transports when surveyed in 2009, which translated to 2,364 transports per 100,000 population.13 The EMS system responds only to emergency calls and does not do interfacility transfers. Dispatch policy is usually not to refuse an ambulance request (especially when it is uncertain if it is an emergency), but nonemergency requests can be redirected to a nonemergency 1-7-7-7 number provided by private ambulances. The public is advised that SCDF does not charge a fee for emergency calls, but if the case is subsequently assessed at the emergency department (ED) to be a nonemergency, a charge will be levied. Emergency ambulances will convey patients to the nearest appropriate hospital by policy, and not by patient choice. Interfacility transports and conveyance af-
ter hospital discharge are usually performed by private ambulance providers. EMS can pronounce death in obvious cases (decapitation, rigor mortis, dependent lividity) but currently do not have termination of resuscitation (trauma or cardiac) policies in the field.
HISTORICAL PERSPECTIVE In Singapore, prehospital trauma care is primarily based on the Anglo-American model and can be said to have begun in 1917 with the acquisition of a motor ambulance by the Singapore General Hospital (SGH) at Outram Road owing to a need to ferry medical cases. The drawbacks of the hospital-based ambulance service were long response times and a lack of fieldrelated paramedic training. In 1928, the Singapore Fire Brigade started an ambulance service in parallel, to transport cases that resulted from road traffic accidents and fire incidents. From 1964 to 1976, a Central Ambulance Service was coordinated by the Emergency Unit at SGH.17 This service dispatched ambulances with a registered nurse, a health attendant, and a driver, and transported more than 10,000 incidents per year with an average response time of 25 minutes.18 While nontrauma calls were handled by ambulances dispatched from emergency departments (EDs), trauma and fire calls were responded to by the Singapore Fire Brigade. During
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FIGURE 3. Proportion of types of calls the Singapore Civil Defence Force responded to from 2007 to 2012.
this period, the Fire Brigade ambulance had an average response time of 15 minutes.19 In 1977, both ambulance services were integrated into an Emergency Ambulance Service (EAS) under the Singapore Fire Brigade, with the ED at SGH providing an advisory service to the EAS on issues like intramuscular analgesia and nebulization. The EAS was a single-tier system staffed by nurses and midwives.17 In 1989, the EAS was absorbed into the SCDF, which then operated a single-tiered fleet of 13 ambulances (population of Singapore 2.9 million), each staffed with an ambulance officer (nurse from the Ministry of Health [MOH] seconded to the role with midwifery experience and training in first aid and basic life support [BLS]), an ambulance attendant (firefighter also trained in first aid and BLS), and an ambulance driver (trained in first aid). By 1993, the number of ambulances had increased to 20 (population of Singapore 3.3 million).17 In 1992, the Fast Response Medic (FRM) scheme (EMTs on motorcycles) was implemented to allow the EAS to provide motorcycle-based initial care to trauma casualties in heavy traffic conditions. The FRMs responded only to trauma cases arising from road traffic accidents. The FRM scheme was associated with a reduction of mean response time from 15 to 8 minutes.20 In 1997, the Medical Advisory Committee (MAC) was established for the EAS, chaired by an emergency physician and comprising two other emergency physicians, a cardiologist, two surgeons, an anesthesiologist, and a pediatrician. The MAC provided medical over-
sight, established a complete array of standardized clinical protocols as well as advised on various aspects of prehospital trauma care, including development of training curriculum for dispatchers. Over the years, a variety of therapies have been added to the scope of practice of the ambulance crews, including splinting of fractures, dextrose infusion for hypoglycemia, nitrous oxide analgesia laryngeal mask airway, intravenous adrenaline,21 and mechanical CPR, among others. In addition, the MAC also introduced priority medical dispatch and dispatch-assisted CPR and treatments for pediatric patients with traumatic emergency conditions into the emergency ambulance service. Singapore EMS was one of the earliest to develop in Asia, especially in Southeast Asia, and paralleled the development of emergency medicine in Singapore.20,22 Emergency medicine was established as a discipline, and EMS has since spread and become established in Asia. Through various bilateral as well as multilateral platforms, such as the Asian Society for Emergency Medicine, Singapore has had a positive impact on this process and the development of trauma care in the region.
TRAINING AND FACILITIES Prehospital Providers The Singapore Armed Forces (SAF) has been training combat medical orderlies since the 1980s. In 1997, to-
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gether with the formation of the MAC, a system was set up to train civilian paramedics under the wing of the SAF’s School of Military Medicine (SMM – now renamed and reorganized as the SAF Military Training Institute, SMTI). A Paramedic Training Committee was also set up to oversee such training. A decision was made to engage the Paramedic Academy of the Justice Institute of British Columbia of Canada to train instructors for the Paramedic Training Wing of the SMM. The resulting training program was 1.5 years long and consisted of three modules, covering a series of anatomy, physiology, and disease lectures, first aid, BLS and basic trauma life support (BTLS), and AED. With completion of on-the-job clinical training, accreditation for such training was granted by the Justice Institute, which was comparable to the EMT-D in the United States and Canada. Eventually a decision was made to share the facilities between SAF and SCDF to avoid duplication of resources, and this eventually led to the phasing out of the ambulances officers. Since then, SCDF has been running its own EMT course for its national servicemen (NSFs) and regulars but paramedics are still sent to SMTI for advanced training. In 2009, the Institute of Technical Education (ITE) started an annual 11-month paramedic course for ITE enrolled nurses to serve a growing need for paramedic services in collaboration with SCDF. Outstanding paramedics are offered overseas attachments and visits to allow exposure to foreign EMS systems. Besides periodic emergency preparedness exercises, many volunteered their services during regional disasters, such as the 1999 “921” earthquake in Taiwan and the 1990 Luzon earthquake in the Philippines.
International Trauma Life Support and Prehospital Trauma Life Support Courses In 1990 the SGH ED introduced the BTLS Program in Singapore22 in an effort to set standards in the initial care of trauma victims, which was targeted at all ambulance officers of the EAS, basic postgraduate trainees in emergency medicine, some trainees in general surgery, and emergency nurses. This training was also extended to the SCDF fast-response medics when they were introduced in 1992. The collaboration with the Justice Institute in 1997 formalized the use of BTLS, later renamed International Trauma Life Support (ITLS), into the trauma training programs for all paramedics. In 2013, the ITLS program for paramedic training was replaced by the Prehospital Trauma Life Support (PHTLS) course, which is regularly offered to prehospital personnel. In addition, paramedics continued to undergo 18 months of training that include classroom lectures and hospital and ambulance attachments. After graduating from the course they are able to admin-
ister oxygen and airway adjuncts, including laryngeal mask airways, immobilize fractures and spinal injuries, and manage intravenous fluids and tamponade bleeding. They are recertified at 6-monthly intervals.
Hospital Providers Emergency medicine was formally recognized by the MOH as an independent clinical specialty in 1984,22 with the first structured postgraduate training program introduced in 1989. Since 2010, emergency medicine training in Singapore has been a 5year residency program offered by three sponsoring institutions that are accredited by the Accreditation Council for Graduate Medical Education International (ACGME-I).23 The Advanced Trauma Life Support (ATLS) course was introduced in 1992 and was made compulsory for all doctors serving military service and for trainees in emergency medicine and general surgery. For general surgeons, the Definitive Surgical Trauma Care course is conducted locally and many orthopedic sur¨ Osteosyngeons attend the Arbeitsgemeinschaft fur thesefragen (AO) trauma course (http://aotrauma. aofoundation.org/).
Hospital Facilities and Institutions Singapore has 6 adult general public hospitals, termed restructured, which means they are run as private companies wholly owned by the government. This includes a hospital that receives adult and child emergencies and a stand-alone women’s and children’s public hospital. There is no dedicated military hospital facility. Total annual patient load is about 600,000. The private hospitals currently do not receive SCDF cases, although private ambulances and international transfers can be arranged to take patients there on request. There are significant differences in the case mix and capabilities of EDs in public and private hospitals in Singapore. The 14 EDs in Singapore (including 7 private EDs) were characterized using the National ED Inventories Instrument in 2007 with complete response rate.24 Of these, 92% reported being capable of treating “trauma, example, motor vehicle crash, gunshot wound.” Excluding the single psychiatric ED, all EDs reported that 20% or less of their patient population arrived by ambulance, with 8 EDs reporting that 2% or less were brought by ambulance. Of these 8 EDs, 7 of them were private sector EDs and 1 was a public pediatric ED. All EDs had round-the-clock physician coverage and most public EDs have round-the-clock stayin emergency medicine specialist coverage. A total of 46% of the EDs have a dedicated computed tomogram scanner. All public EDs have 24-hour anesthesia coverage within 30 minutes of call. Plastic surgery consultants would be available immediately in 2 public EDs and 1 private ED.
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Public EDs have a trauma activation code team involving inpatient surgical services to expedite management of polytrauma. All public hospitals are equipped with stay-in general surgery and orthopedic teams (at least senior resident level). All public hospitals have neurosurgical and vascular consultations available round-the-clock. Two public hospitals have in-house cardiothoracic departments, one has a thoracic department, and the National Heart Centre provides nationwide support for extracorporeal membrane oxygenation techniques. The Burns Center at SGH is the only specialized burns unit in Southeast Asia, and houses a burns intensive care unit and a specialized burns operating theater. As of 2013, there are 118 registered emergency medicine specialists, of which 5.9% are in private practice and 268 are registered general surgeons.25
UNIT FOR PREHOSPITAL EMERGENCY CARE In 2011, a joint MOH-MHA (Ministry of Home Affairs) proposal for prehospital emergency care (PEC) was approved, of which one of the components was the establishment of a small office, called the Unit for Prehospital Emergency Care (UPEC), to assist in the provision of medical oversight and systems decision support, specifically to augment SCDF’s medical capabilities. The establishment of a dedicated unit to coordinate, monitor, and implement the various PEC strategies, as well as to provide clinical and operational oversight on PEC work, forms an integral part of the implementation plan for PEC. UPEC focuses on four key areas: 1) standards and sector development, 2) operational coordination and medical oversight, 3) professional training and development, and 4) research and development. The vision is for Singapore to possess a world-class PEC system, readily accessible to all while providing excellent patient care outcomes.
NATIONAL TRAUMA COMMITTEE The National Trauma Committee (NTC) was formed in 2008, comprising representatives from the restructured hospitals, the SCDF, SAF, and MOH. One major achievement of the NTC was the development of benchmarks for acute hospitals to deliver optimal trauma care for the best clinical outcomes.26 Potential policy considerations for the future of prehospital trauma care include models of care that optimize the limited resources in Singapore and utilize the national trauma registry data to inform policy as well as injury prevention.
RESEARCH AND THE NATIONAL TRAUMA REGISTRY Singapore General Hospital started a single-institution trauma registry in 1998 and Tan Tock Seng Hospital in
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2003. The National Trauma Registry (NTR) was formally established in 2011, and is currently managed by the National Registry of Diseases Office (NRDO). The NRDO collects and analyzes epidemiologic data to support the national disease management plans, policy formulation, and program planning. The NTR receives data from the Integrated Trauma System, which is a national, web-based platform contributed by the 6 restructured hospital systems and SCDF. The registry records follow patients for up to 12 months. The data from the NTR has been used mainly for audit purposes and for evidence-based research to inform system design for local emergency trauma care.
LOOKING TO THE FUTURE Prehospital emergency care in Singapore has taken shape over almost a century. The development of prehospital trauma care systems in island city–state Singapore faces unique challenges as a result of its land area and population density. Examples of such challenges are the lack of surge capacity or responsive mutual aid agreements. While some prehospital treatment modalities have been proven to improve outcomes in trauma care in other environments,6 their applicability to Singapore needs to be adapted to the unique circumstances. The measurement of quantifiable outcomes is necessary to assess the effectiveness of the system. Some studies have suggested that rapid EMS response time has improved survival only in nontraumatic cardiac arrest,27,28 whereas in trauma, the benefits of prehospital advanced trauma care remain less clear. Hence, studies on the impact of quicker evacuations to hospitals and faster prehospital lifesaving interventions in trauma and its impact on patient survival ought to be carried out on this developing system. Moreover, longterm outcomes, such as disability from trauma, can be included to assist in future improvement and development of the existing system. The results obtained can aid in distribution of resources to the right infrastructures in order to obtain better returns in prehospital trauma care. One example would be to allocate funding for enhancing triage capabilities of the prehospital services in order to improve the accuracy of trauma surveillance and data collection for future research. Prehospital techniques, tactics, and procedures in both peacetime and the setting of national emergencies and mass casualty incidents need to be continually developed. The introduction of techniques such as intraosseous access and inhaled methoxyflurane for analgesia are currently being studied. Tourniquets, needle thoracostomy, and Cricothyroidotomy may be in the pipeline. The ability of the prehospital medical personnel to operate in austere environments while managing casualties has periodically been put to the test during disaster events and would be sharpened
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by ongoing training in this area. New technology such as tele-medical communications devices could be a future direction for paramedics to obtain extra support at the scene and improve patient care.29 Future studies should be instituted for such methods and tools to substantiate outcome effects and complications. The progression of prehospital trauma care in Singapore may serve as lessons for the future development of prehospital trauma systems in similar environments. A good trauma system also assumes the presence of an effective hospital system, which is integral to prehospital trauma care. This chain of survival is only as strong as the weakest link.
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Søreide K. Epidemiology of major trauma. Br J Surg. 2009;96(7):697–8. Ministry of Health Singapore: Health Facts Singapore. 2012. Available at: www.moh.gov.sg/content/moh web/home/ statistics/Health Facts Singapore/Principal Causes of Death. html. Marson AC, Thomson JC. The influence of prehospital trauma care on motor vehicle crash mortality. J Trauma. 2001;50(5):917–20; discussion 920–1. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999;5(3):203–7. Hargarten SW, Karlson T. Injury control. A crucial aspect of emergency medicine. Emerg Med Clin North Am. 1993;11(1):255–62. Williamson K, Ramesh R, Grabinsky A. Advances in prehospital trauma care. Int J Crit Illn Inj Sci. 2011;1(1):44–50. World Health Organization. Prehospital Trauma Care Systems. Geneva: WHO; 2005. Statistics Singapore–Department of Statistics Singapore. Available at: www.singstat.gov.sg/statistics/latest data.html#14. Land Area, Population, and Density for Places and (in selected states) County Subdivisions: 2010. Available at: www.census.gov/2010census/. International Monetary Fund. World Economic Outlook Database 2014. Available at: www.imf.org/external/ pubs/ft/weo/2014/01/weodata/index.aspx Lim J. Myth or Magic: The Singapore Healthcare System. Singapore: Select Publishing; 2013. World Health Organization. The Health Report 2000: Health Systems: Improving Performance. Geneva: WHO; 2000. Shin S Do, Ong MEH, Tanaka H, et al. Comparison of emergency medical services systems across Pan-Asian countries: a web-based survey. Prehosp Emerg Care. 2012;16(4):477–96.
415 14. Ong MEH, Ng FSP, Overton J, et al. Geographic-time distribution of ambulance calls in Singapore: utility of geographic information system in ambulance deployment (CARE 3). Ann Acad Med Singapore. 2009;38(3):184–91. 15. Lateef F, Anantharaman V. Delays in the EMS response to and the evacuation of patients in high-rise buildings in Singapore. Prehosp Emerg Care. 4(4):327–32. 16. Singapore Civil Defence Force. Annual Statistics Report: Emergency Ambulance Service Statistics 2013. Available at: www.scdf.gov.sg/content/scdf internet/en/general/news/stat istics.html 17. Lateef F. The emergency medical services in Singapore. Resuscitation. 2006;68(3):323–8. 18. Fung WG. The organisation of emergency unit Outram Road General Hospital 1964–1968. Singapore Med J. 1971;12(1): 37–41. 19. Foo Kwee Hiang. My experience in the Singapore Fire Brigade Service Emergency Ambulance Section. Nurs J Singapore. 23:44–5. 20. Lateef F, Anantharaman V. Emergency medical services in Singapore. Can J Emerg Med. 2000;2(4):272–5. 21. Ong MEH, Tan EH, Ng FSP, et al. Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Ann Emerg Med. 2007;50(6):635–42. 22. Lim SH, Anantharaman V. Emergency medicine in Singapore: past, present, and future. Ann Emerg Med. 1999;33(3): 338–43. 23. Tan TJ, Tan KY. Re: general surgery (GS) residency selection process: a comparison between Singapore (Singhealth) and United States. Ann Acad Med Singapore. 2014;43(5):291–2. 24. Wen LS, Venkataraman A, Sullivan AF, Camargo CA. National inventory of emergency departments in Singapore. Int J Emerg Med. 2012;5(1):38. 25. Singapore Medical Council. Annual Report 2013. Available at: www.healthprofessionals.gov.sg/content/hprof/smc/en/top nav/publication/annual reports.html 26. Speech by Director of Medical Services, Prof K. Satkunanantham, at the Opening Ceremony of the 7th Singapore Trauma Conference 2013, 13 April 2013. Available at: /www.moh.gov.sg/content/moh web/home/pressRoom/spe eches d/2013/speech-by-director-of-medical-services–profk–satkunanantham–.html 27. De Maio VJ, Stiell IG, Wells GA, Spaite DW. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med. 2003;42(2):242–50. 28. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance of rapid provision and implications for program planning. JAMA. 1979;241(18):1905–7. 29. Bergrath S, Czaplik M, Rossaint R, et al. Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations. Scand J Trauma Resusc Emerg Med. 2013;21:54.
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Prehospital Trauma Care in Singapore Andrew Fu Wah Ho MBBS, David Chew MBChB, MRCS, Ting Hway Wong MBBCh, MPH, Yih Yng Ng MBBS, MPH, MBA, Pin Pin Pek PgDip, Swee Han Lim MBBS, Venkataraman Anantharaman MBBS & Marcus Eng Hock Ong MBBS, MPH To cite this article: Andrew Fu Wah Ho MBBS, David Chew MBChB, MRCS, Ting Hway Wong MBBCh, MPH, Yih Yng Ng MBBS, MPH, MBA, Pin Pin Pek PgDip, Swee Han Lim MBBS, Venkataraman Anantharaman MBBS & Marcus Eng Hock Ong MBBS, MPH (2015) Prehospital Trauma Care in Singapore, Prehospital Emergency Care, 19:3, 409-415, DOI: 10.3109/10903127.2014.980477 To link to this article: http://dx.doi.org/10.3109/10903127.2014.980477
Published online: 12 Dec 2014.
Submit your article to this journal
Article views: 109
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Date: 05 November 2015, At: 17:27
INTERNATIONAL EMS
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PREHOSPITAL TRAUMA CARE IN SINGAPORE Andrew Fu Wah Ho, MBBS, David Chew, MBChB, MRCS, Ting Hway Wong, MBBCh, MPH, Yih Yng Ng, MBBS, MPH, MBA, Pin Pin Pek, PgDip, Swee Han Lim, MBBS, Venkataraman Anantharaman, MBBS, Marcus Eng Hock Ong, MBBS, MPH
INTRODUCTION
ABSTRACT Prehospital emergency care in Singapore has taken shape over almost a century. What began as a hospital-based ambulance service intended to ferry medical cases was later complemented by an ambulance service under the Singapore Fire Brigade to transport trauma cases. The two ambulance services would later combine and come under the Singapore Civil Defence Force. The development of prehospital care systems in island city–state Singapore faces unique challenges as a result of its land area and population density. This article defines aspects of prehospital trauma care in Singapore. It outlines key historical milestones and current initiatives in service, training, and research. It makes propositions for the future direction of trauma care in Singapore. The progress Singapore has made given her circumstances may serve as lessons for the future development of prehospital trauma systems in similar environments. Key words: Singapore; trauma; prehospital emergency care; emergency medical services
Care for the multiply injured patient is a global health concern. Trauma results in 10% of all deaths worldwide annually1 and exacts a large societal and economic toll on society. Accidents, poisoning and violence was the fifth principal cause of death and the leading cause of hospital admissions in Singapore in 2011,2 mirroring worldwide trends. Many injuryrelated fatalities may be prevented or have their severity reduced by adequate prehospital trauma care.3–6 The magnitude of the problem led to the convening of the Prehospital Care Meeting at the World Health Organization headquarters in Geneva in 2004, which culminated in recommendations for the development of prehospital trauma care systems.7
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Singapore is one of the smallest countries in the world with a population of 5.3 million, a land area of 276.1 square miles (715.1 square kilometers) and a population density of 20,065 persons per square mile.8 While less crowded than New York (27,779 per square mile), it is much more crowded than most North American cities, including San Francisco (17,246/sq mi), Boston (13,321/sq mi), and Philadelphia (11,234/sq mi) or Washington, DC (9,800/sq mile).9 Singapore has a gross domestic product of 295.7 billion dollars10 and a life expectancy of 82.1 years. Singapore has a mixed health-care system,11 where the public health-care system is funded through a system of compulsory savings, subsidies, and price controls.12
Singapore’s Peculiar Circumstances
Received 16 June, 2014 from Singhealth Emergency Medicine Residency Program, Singapore Health Services, Department of Emergency Medicine, Singapore General Hospital, Singapore (AFWH), Unit for Prehospital Emergency Care, Ministry of Health, Singapore (DC), Department of General Surgery, Singapore General Hospital, Singapore (THW), Medical Department, Singapore Civil Defence Force, Singapore (YYN), Department of Emergency Medicine, Singapore General Hospital, Singapore (PPP, SHL, VA, MEHO). Revision received 17 September, 2014; accepted for publication 23 September, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. We would like to thank Lam Shao Wei from Health Services Research, Division of Research, Singapore General Hospital for his advice on SCDF’s catchment policy and provision of Figure 1.
Emergency Medical Services Emergency medical services (EMS) are provided by the Singapore Civil Defence Force (SCDF). Prehospital emergency care in Singapore was characterized in a survey of emergency medical services (EMS) directors in 2013 comparing the structure, scope of services,
Address correspondence to Andrew Fu Wah Ho, c/o Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608. Tel: +65 6321 3590. Fax: +65 6226 0294. E-mail: [email protected] doi: 10.3109/10903127.2014.980477
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410 and delivery characteristics among seven Asian countries.13 SCDF operates a fleet of 46 ambulances and 15 “fast response paramedics” (FRP) on motorcycles along with 41 first response fire-bikers in a fire-based system activated by a centralized 9-9-5 dispatching system and utilizes computer-aided dispatch protocols (Tritech Software Systems, San Diego, CA, USA). Dispatchers are predominantly firefighters, but also include paramedics and dispatch nurses. They are able to give prearrival instructions for cardiopulmonary resuscitation (CPR), use of an automated external defibrillator (AED), choking, hemorrhage control, etc. Dispatch also has global positioning satellite automatic vehicle location systems and road traffic monitoring systems. Ambulances are dispatched from 15 stations and 25 fire posts. The ambulance service is staffed by salaried personnel, provided free of charge, and is publicly funded. SCDF ambulances have a crew of 3: the crew leader, who is locally called “paramedic” (equivalent to North America’s emergency medical technician (EMT)intermediate in scope of practice), the ambulance assistant/EMT (equivalent to North America’s EMTbasic), and the driver (first aider, now being upgraded to North America’s EMT-basic level). In addition, SCDF uses motorcycle-based FRP, who are trained to the same level as the ambulance paramedics. We have also recently added first-responder “fire-bikers,” who
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are motorcycle-based firefighter-EMT (basic). Motorcycles are dispatched for major trauma, including motor vehicle collisions with resulting traffic congestion, cardiac arrest, and medical emergencies that could possibly result in cardiac arrest (unconscious, breathing difficulties). Paramedics are a distinct vocation, and are not cross trained as firefighters. However, operationally they come under the command and control of the fire service. Some firefighters are now being cross-trained as basic EMTs. Ambulance treatment is protocol driven, based on indirect medical control. However, ambulance crews are able to contact hospital-based physicians for advice or ask for a hospital medical team in cases of prolonged extrication, for example. In 2009 there were 200 providers (4.0 per 100,000 population) and 0.8 ambulances per 100,000 population. SCDF uses a catchment zone policy where patients from defined geographic areas will be conveyed to the public hospital nearest to the incident location. Mean call receipt to arrival at the scene was 8 minutes, with a standard deviation of 4.8 minutes in 2006.14 A consequence of the highly urbanized setting with more than 80% of the population residing in high rise apartments is that there is often a delay between on-scene and patient contact time, related to factors such as elevators, corridors, and stairways.15 Figure 1
FIGURE 1. Singapore Civil Defence Force catchment zones and travel time coverage.
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FIGURE 2. Annual ambulance call volume of the Singapore Civil Defence Force from 2007 to 2012.
shows the catchment zones of SCDF and the average travel time coverage of each zone in 2011. SCDF responded to 150,155 calls between January and December 2013, of which 96.1% were classified as emergency calls.16 Of these, 7.6% were road traffic accidents and 18.3% were trauma cases related to industrial accidents, falls, and assaults. SCDF annual reports indicate that there is a steady increase since 1998 in both call volume and proportion of calls classified as emergency calls. Conveyance rate was 99.9% in 2006.14 Figures 2 and 3 show the annual ambulance call volume and proportion of the types of calls the SCDF responded to between 2007 and 2012. SCDF undertook 117,896 transports when surveyed in 2009, which translated to 2,364 transports per 100,000 population.13 The EMS system responds only to emergency calls and does not do interfacility transfers. Dispatch policy is usually not to refuse an ambulance request (especially when it is uncertain if it is an emergency), but nonemergency requests can be redirected to a nonemergency 1-7-7-7 number provided by private ambulances. The public is advised that SCDF does not charge a fee for emergency calls, but if the case is subsequently assessed at the emergency department (ED) to be a nonemergency, a charge will be levied. Emergency ambulances will convey patients to the nearest appropriate hospital by policy, and not by patient choice. Interfacility transports and conveyance af-
ter hospital discharge are usually performed by private ambulance providers. EMS can pronounce death in obvious cases (decapitation, rigor mortis, dependent lividity) but currently do not have termination of resuscitation (trauma or cardiac) policies in the field.
HISTORICAL PERSPECTIVE In Singapore, prehospital trauma care is primarily based on the Anglo-American model and can be said to have begun in 1917 with the acquisition of a motor ambulance by the Singapore General Hospital (SGH) at Outram Road owing to a need to ferry medical cases. The drawbacks of the hospital-based ambulance service were long response times and a lack of fieldrelated paramedic training. In 1928, the Singapore Fire Brigade started an ambulance service in parallel, to transport cases that resulted from road traffic accidents and fire incidents. From 1964 to 1976, a Central Ambulance Service was coordinated by the Emergency Unit at SGH.17 This service dispatched ambulances with a registered nurse, a health attendant, and a driver, and transported more than 10,000 incidents per year with an average response time of 25 minutes.18 While nontrauma calls were handled by ambulances dispatched from emergency departments (EDs), trauma and fire calls were responded to by the Singapore Fire Brigade. During
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FIGURE 3. Proportion of types of calls the Singapore Civil Defence Force responded to from 2007 to 2012.
this period, the Fire Brigade ambulance had an average response time of 15 minutes.19 In 1977, both ambulance services were integrated into an Emergency Ambulance Service (EAS) under the Singapore Fire Brigade, with the ED at SGH providing an advisory service to the EAS on issues like intramuscular analgesia and nebulization. The EAS was a single-tier system staffed by nurses and midwives.17 In 1989, the EAS was absorbed into the SCDF, which then operated a single-tiered fleet of 13 ambulances (population of Singapore 2.9 million), each staffed with an ambulance officer (nurse from the Ministry of Health [MOH] seconded to the role with midwifery experience and training in first aid and basic life support [BLS]), an ambulance attendant (firefighter also trained in first aid and BLS), and an ambulance driver (trained in first aid). By 1993, the number of ambulances had increased to 20 (population of Singapore 3.3 million).17 In 1992, the Fast Response Medic (FRM) scheme (EMTs on motorcycles) was implemented to allow the EAS to provide motorcycle-based initial care to trauma casualties in heavy traffic conditions. The FRMs responded only to trauma cases arising from road traffic accidents. The FRM scheme was associated with a reduction of mean response time from 15 to 8 minutes.20 In 1997, the Medical Advisory Committee (MAC) was established for the EAS, chaired by an emergency physician and comprising two other emergency physicians, a cardiologist, two surgeons, an anesthesiologist, and a pediatrician. The MAC provided medical over-
sight, established a complete array of standardized clinical protocols as well as advised on various aspects of prehospital trauma care, including development of training curriculum for dispatchers. Over the years, a variety of therapies have been added to the scope of practice of the ambulance crews, including splinting of fractures, dextrose infusion for hypoglycemia, nitrous oxide analgesia laryngeal mask airway, intravenous adrenaline,21 and mechanical CPR, among others. In addition, the MAC also introduced priority medical dispatch and dispatch-assisted CPR and treatments for pediatric patients with traumatic emergency conditions into the emergency ambulance service. Singapore EMS was one of the earliest to develop in Asia, especially in Southeast Asia, and paralleled the development of emergency medicine in Singapore.20,22 Emergency medicine was established as a discipline, and EMS has since spread and become established in Asia. Through various bilateral as well as multilateral platforms, such as the Asian Society for Emergency Medicine, Singapore has had a positive impact on this process and the development of trauma care in the region.
TRAINING AND FACILITIES Prehospital Providers The Singapore Armed Forces (SAF) has been training combat medical orderlies since the 1980s. In 1997, to-
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gether with the formation of the MAC, a system was set up to train civilian paramedics under the wing of the SAF’s School of Military Medicine (SMM – now renamed and reorganized as the SAF Military Training Institute, SMTI). A Paramedic Training Committee was also set up to oversee such training. A decision was made to engage the Paramedic Academy of the Justice Institute of British Columbia of Canada to train instructors for the Paramedic Training Wing of the SMM. The resulting training program was 1.5 years long and consisted of three modules, covering a series of anatomy, physiology, and disease lectures, first aid, BLS and basic trauma life support (BTLS), and AED. With completion of on-the-job clinical training, accreditation for such training was granted by the Justice Institute, which was comparable to the EMT-D in the United States and Canada. Eventually a decision was made to share the facilities between SAF and SCDF to avoid duplication of resources, and this eventually led to the phasing out of the ambulances officers. Since then, SCDF has been running its own EMT course for its national servicemen (NSFs) and regulars but paramedics are still sent to SMTI for advanced training. In 2009, the Institute of Technical Education (ITE) started an annual 11-month paramedic course for ITE enrolled nurses to serve a growing need for paramedic services in collaboration with SCDF. Outstanding paramedics are offered overseas attachments and visits to allow exposure to foreign EMS systems. Besides periodic emergency preparedness exercises, many volunteered their services during regional disasters, such as the 1999 “921” earthquake in Taiwan and the 1990 Luzon earthquake in the Philippines.
International Trauma Life Support and Prehospital Trauma Life Support Courses In 1990 the SGH ED introduced the BTLS Program in Singapore22 in an effort to set standards in the initial care of trauma victims, which was targeted at all ambulance officers of the EAS, basic postgraduate trainees in emergency medicine, some trainees in general surgery, and emergency nurses. This training was also extended to the SCDF fast-response medics when they were introduced in 1992. The collaboration with the Justice Institute in 1997 formalized the use of BTLS, later renamed International Trauma Life Support (ITLS), into the trauma training programs for all paramedics. In 2013, the ITLS program for paramedic training was replaced by the Prehospital Trauma Life Support (PHTLS) course, which is regularly offered to prehospital personnel. In addition, paramedics continued to undergo 18 months of training that include classroom lectures and hospital and ambulance attachments. After graduating from the course they are able to admin-
ister oxygen and airway adjuncts, including laryngeal mask airways, immobilize fractures and spinal injuries, and manage intravenous fluids and tamponade bleeding. They are recertified at 6-monthly intervals.
Hospital Providers Emergency medicine was formally recognized by the MOH as an independent clinical specialty in 1984,22 with the first structured postgraduate training program introduced in 1989. Since 2010, emergency medicine training in Singapore has been a 5year residency program offered by three sponsoring institutions that are accredited by the Accreditation Council for Graduate Medical Education International (ACGME-I).23 The Advanced Trauma Life Support (ATLS) course was introduced in 1992 and was made compulsory for all doctors serving military service and for trainees in emergency medicine and general surgery. For general surgeons, the Definitive Surgical Trauma Care course is conducted locally and many orthopedic sur¨ Osteosyngeons attend the Arbeitsgemeinschaft fur thesefragen (AO) trauma course (http://aotrauma. aofoundation.org/).
Hospital Facilities and Institutions Singapore has 6 adult general public hospitals, termed restructured, which means they are run as private companies wholly owned by the government. This includes a hospital that receives adult and child emergencies and a stand-alone women’s and children’s public hospital. There is no dedicated military hospital facility. Total annual patient load is about 600,000. The private hospitals currently do not receive SCDF cases, although private ambulances and international transfers can be arranged to take patients there on request. There are significant differences in the case mix and capabilities of EDs in public and private hospitals in Singapore. The 14 EDs in Singapore (including 7 private EDs) were characterized using the National ED Inventories Instrument in 2007 with complete response rate.24 Of these, 92% reported being capable of treating “trauma, example, motor vehicle crash, gunshot wound.” Excluding the single psychiatric ED, all EDs reported that 20% or less of their patient population arrived by ambulance, with 8 EDs reporting that 2% or less were brought by ambulance. Of these 8 EDs, 7 of them were private sector EDs and 1 was a public pediatric ED. All EDs had round-the-clock physician coverage and most public EDs have round-the-clock stayin emergency medicine specialist coverage. A total of 46% of the EDs have a dedicated computed tomogram scanner. All public EDs have 24-hour anesthesia coverage within 30 minutes of call. Plastic surgery consultants would be available immediately in 2 public EDs and 1 private ED.
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Public EDs have a trauma activation code team involving inpatient surgical services to expedite management of polytrauma. All public hospitals are equipped with stay-in general surgery and orthopedic teams (at least senior resident level). All public hospitals have neurosurgical and vascular consultations available round-the-clock. Two public hospitals have in-house cardiothoracic departments, one has a thoracic department, and the National Heart Centre provides nationwide support for extracorporeal membrane oxygenation techniques. The Burns Center at SGH is the only specialized burns unit in Southeast Asia, and houses a burns intensive care unit and a specialized burns operating theater. As of 2013, there are 118 registered emergency medicine specialists, of which 5.9% are in private practice and 268 are registered general surgeons.25
UNIT FOR PREHOSPITAL EMERGENCY CARE In 2011, a joint MOH-MHA (Ministry of Home Affairs) proposal for prehospital emergency care (PEC) was approved, of which one of the components was the establishment of a small office, called the Unit for Prehospital Emergency Care (UPEC), to assist in the provision of medical oversight and systems decision support, specifically to augment SCDF’s medical capabilities. The establishment of a dedicated unit to coordinate, monitor, and implement the various PEC strategies, as well as to provide clinical and operational oversight on PEC work, forms an integral part of the implementation plan for PEC. UPEC focuses on four key areas: 1) standards and sector development, 2) operational coordination and medical oversight, 3) professional training and development, and 4) research and development. The vision is for Singapore to possess a world-class PEC system, readily accessible to all while providing excellent patient care outcomes.
NATIONAL TRAUMA COMMITTEE The National Trauma Committee (NTC) was formed in 2008, comprising representatives from the restructured hospitals, the SCDF, SAF, and MOH. One major achievement of the NTC was the development of benchmarks for acute hospitals to deliver optimal trauma care for the best clinical outcomes.26 Potential policy considerations for the future of prehospital trauma care include models of care that optimize the limited resources in Singapore and utilize the national trauma registry data to inform policy as well as injury prevention.
RESEARCH AND THE NATIONAL TRAUMA REGISTRY Singapore General Hospital started a single-institution trauma registry in 1998 and Tan Tock Seng Hospital in
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2003. The National Trauma Registry (NTR) was formally established in 2011, and is currently managed by the National Registry of Diseases Office (NRDO). The NRDO collects and analyzes epidemiologic data to support the national disease management plans, policy formulation, and program planning. The NTR receives data from the Integrated Trauma System, which is a national, web-based platform contributed by the 6 restructured hospital systems and SCDF. The registry records follow patients for up to 12 months. The data from the NTR has been used mainly for audit purposes and for evidence-based research to inform system design for local emergency trauma care.
LOOKING TO THE FUTURE Prehospital emergency care in Singapore has taken shape over almost a century. The development of prehospital trauma care systems in island city–state Singapore faces unique challenges as a result of its land area and population density. Examples of such challenges are the lack of surge capacity or responsive mutual aid agreements. While some prehospital treatment modalities have been proven to improve outcomes in trauma care in other environments,6 their applicability to Singapore needs to be adapted to the unique circumstances. The measurement of quantifiable outcomes is necessary to assess the effectiveness of the system. Some studies have suggested that rapid EMS response time has improved survival only in nontraumatic cardiac arrest,27,28 whereas in trauma, the benefits of prehospital advanced trauma care remain less clear. Hence, studies on the impact of quicker evacuations to hospitals and faster prehospital lifesaving interventions in trauma and its impact on patient survival ought to be carried out on this developing system. Moreover, longterm outcomes, such as disability from trauma, can be included to assist in future improvement and development of the existing system. The results obtained can aid in distribution of resources to the right infrastructures in order to obtain better returns in prehospital trauma care. One example would be to allocate funding for enhancing triage capabilities of the prehospital services in order to improve the accuracy of trauma surveillance and data collection for future research. Prehospital techniques, tactics, and procedures in both peacetime and the setting of national emergencies and mass casualty incidents need to be continually developed. The introduction of techniques such as intraosseous access and inhaled methoxyflurane for analgesia are currently being studied. Tourniquets, needle thoracostomy, and Cricothyroidotomy may be in the pipeline. The ability of the prehospital medical personnel to operate in austere environments while managing casualties has periodically been put to the test during disaster events and would be sharpened
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by ongoing training in this area. New technology such as tele-medical communications devices could be a future direction for paramedics to obtain extra support at the scene and improve patient care.29 Future studies should be instituted for such methods and tools to substantiate outcome effects and complications. The progression of prehospital trauma care in Singapore may serve as lessons for the future development of prehospital trauma systems in similar environments. A good trauma system also assumes the presence of an effective hospital system, which is integral to prehospital trauma care. This chain of survival is only as strong as the weakest link.
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