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Designing a prehospital system for a developing country: Estimated cost and benefits
Designing a Prehospital System for a Developing Country: Estimated Cost and Benefits MARK HAUSWALD, MD, ERNEST YEOH, MBCHB, FRCS Many of the costs associated with prehospital care in developed countries are covered in budgets for fire suppression, police services, and the like. Determining these costs is therefore difficult. The costs and benefits of developing a prehospital care system for Kuala Lumpur, Malaysia, which now has essentially no emergency medical services (EMS) system, were estimated. Prehospital therapies that have been suggested to decrease mortality were identified. A minimal prehospital system was designed to deliver these treatments in Kuala Lumpur. The potential benefit of these therapies was calculated by using statistics from the United States corrected for demographic differences between the United States and Malaysia. Costs were extrapolated from the current operating budget of the Malaysian Red Crescent Society. Primary dysrhythmias are responsible for almost all potentially survivable cardiac arrests. A system designed to deliver a defibrillator to 85% of arrests within 6 minutes would require an estimated 48 ambulances. Kuala Lumpur has approximately 120 prehospital arrhythmic deaths per year. A 6% resuscitation rate was chosen for the denominator, resulting in seven survivors. Half of these would be expected to have significant neurological damage. Ambulances cost $53,000 (US dollars) to operate per year in Kuala Lumpur; 48 ambulances would cost a total of $2.5 million. Demographic factors and traffic problems would significantly increase the cost per patient. Other therapies, including medications, airway management, and trauma care, were discounted because both their additional cost and their benefit are small. Transport of patients (including trauma) is now performed by police or private vehicle and would probably take longer by ambulance. A prehospital system for Kuala Lumpur would cost approximately $2.5 million per year. It might save seven lives, three of which would be marred by significant neurological injury. Developing countries would do well to consider alternatives to a North American EMS model. (Am J Emerg Med 1997;15:600-603. Copyright © 1997 by W.B. Saunders Company) Most developed nations have complex ambulance systems to transport patients to hospitals while delivering emergency care. Developing nations are looking at these systems in an attempt to modernize health care delivery. These systems are quite expensive. Are they a wise, cost-effective addition to a national health care budget, or would the resources be better spent on a locally developed prehospital system? Unfortunately, no study has examined From the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, and the Accident and Emergency Unit, Primary Care Department, University of Malaya, Kuala Lumpur, Malaysia. Manuscript received January 10, 1997, returned February 16, 1997, revision received May 2, 1997, accepted May 20, 1997. Address reprint requests to Dr Hauswald, Associate Professor, University of New Mexico School of Medicine, Department of Emergency Medicine, Ambulatory Care Center 4-West, Albuquerque, NM 87131-5246. Key Words: Cardiac arrest, resuscitation, emergency medical services. Copyright © 1997 by W.B. Saunders Company 0735-6757/97/1506-001455.00/0 600
the real cost-benefit ratio for development of a prehospital emergency care system. Although the marginal value of adding specific therapies to a prehospital system is frequently analyzed, this is usually done in developed systems in which major costs, in particular personnel and ambulances, are already paid for. We used data available from fully developed prehospital systems and applied them to the demographic situation of Malaysia, a developing country with a rudimentary ambulance system, to estimate the desirability of developing a prehospital system similar to that used in most of North America.
METHODS Prehospital therapies that have been shown to decrease mortality were identified. A minimal prehospital system was designed to deliver these therapies in Malaysia. The cost of this system was calculated by taking the known cost of operating ambulances in Kuala Lumpur and modifying this to account for the additional equipment and personnel required. The potential benefit of these therapies was calculated by using statistics for the United States corrected for the demographic differences between the United States and Malaysia. Although almost any emergency therapy can be delivered outside the hospital, provided the prehospital personnel are adequately trained, we only analyzed therapies that are commonly used by paramedical personnel in North America. One disease process is responsible for almost all survivable prehospital cardiac arrests: the development of sudden arrhythmias, particularly ventricular fibrillation. One therapy is essential to benefit sudden arrhythmias: early defibrillation. The effectiveness of prehospital defibrillation is highly dependent on the underlying emergency medical services (EMS) system. Survival to hospital discharge rates of < 1% to 25% have been reported, H° although the largest cities reported 1% and 2%, partly because of difficulties in gaining access to the patients. 8,9The only report from a developing country reported 1.4%. 1° We chose 6% for our estimate because this is the overall survival to hospital discharge in Albuquerque, which we used for our primary comparison (data from other cities are also used for comparison in Table 1). Of surviving patients, approximately half have significant neurologica.[ injury. 7,11-14Half of survivors die within 3 years. 15 Survival is rare if defibrillation is delayed more than 5 to 10 minutes after arrest. 16We developed our model based on delivery of a defibrillator to 85% of patients within 6 minutes of system notification. Other therapies, such as advanced airway management, medications, and pacing, are much less effective than defibrillation. 1719 Although they may save a few patients with primary cardiac arrest or other medical problems, the cost of adding them to a system is small, and we chose to disregard both their cost and benefit. Prehospital care of trauma victims is more complex. For most injuries, definitive therapy requires the resources of an Emergency Department or Operating Room. Clearly, rapid transport to the
HAUSWALD AND YEOH • PREHOSPITAL SYSTEM FOR A DEVELOPING COUNTRY
hospital is more important than any pre-hospital therapy. 2°-21 Specific therapies that provide little or no measurable benefit include medical antishock trousers (MAST), 22intravenous fluids, 23 and medications. Early airway management may benefit patients with obstruction caused by facial injuries and perhaps those with severe brain injuries, but the former must be treated within minutes of the injury, and most of the latter will have poor outcomes despite the most aggressive care. Artificial ventilation is necessary for patients with high spinal lesions, but must be delivered within a few minutes of the accident. These patients rarely survive in any system. Review of medical records from Albuquerque showed no such patients surviving to hospital discharge during a 5-year period, No study documenting improved outcome in trauma patients because of airway management has been published. The additional cost of equipment and training needed for these therapies is small, and we ignored it in our analysis. Other therapies such spinal and other fracture immobilization may reduce short-or long-term morbidity but would rarely be expected to affect mortality. Although approximately 2% to 10% of seriously injured patients are thought to have unstable cervical spines, z4-26 it is not clear how many of these are affected by prehospital management. We were unable to find any studies that document a decrease in morbidity because of prehospital care. The systems we used for a primary comparison are quite different. Albuquerque, New Mexico, is a city of 385,000 covering 345 square kilometers. It is laid out in a grid pattern, all streets are mapped and signed, and house numbers are sequential by city block. Albuquerque currently uses a two-level priority response system (not all ambulances are available at all times), with approximately 11 transport ambulances and an additional 31 first-responding vehicles with defibrillators staffed by fire department emergency medical technicians (EMTs), These vehicles respond to approximately 35,000 emergency calls per year. This is comparable to other North American systems in terms of ambulances per survivor. Kuala Lumpur, Malaysia, is a city of 1.1 million and covers 243 square kilometers. It is laid out in isolated sections, and mapping and signage are incomplete. Kuata Lumpur currently has approximately 24 ambulances in service. Most ambulances are operated by factories or private hospitals for the transportation of their own patients. Only 8 ambulances are used primarily for emergency response within the federal district. Equipment costs are comparable between the United States and Malaysia because the equipment market is international in scope and import duties into Malaysia are only 3% for medical equipment. Personnel and therefore maintenance is less expensive in Malaysia. The Red Crescent Society operates eight minivan-based ambulances 24 hours per day on a budget of $367,000 (all figures are in US dollars as of 1993). This includes personnel, ambulance purchase, and maintenance, but only minimal equipment. Adding semiautomatic defibrillators and additional equipment, a modem dispatch system, and a modest pay raise commensurate with the additional training would increase this by approximately 15% to $53,000 per ambulance. We estimate that a prehospital system similar to Albuquerque's would require 22 first-response vehicles based on Kuala Lumpur's size plus 26 ambulances based on its population. This would cost $2.5 million per year.
RESULTS Malaysia has a low incidence of coronary artery disease probably primarily because of its population's youthful average age; in 1990, 352 of the 4,779 deaths in Kuala Lumpur were caused by myocardial infarcts (7.4%). 27 In the United States, approximately one quarter of all deaths are caused by ischemic heart disease, 28 half of these are sudden arrhythmic deaths, 29 and two thirds of the sudden deaths occur out of hospital. 3° The latter numbers are not particu-
601
laxly dependent on the EMS system. Most cases of sudden death occur before help can be sought, and even in the United States where much effort has been spent on educating the public on the symptoms of an infarction, the average patient delays 2 hours before notifying the EMS system. 3° Extrapolating these statistics produces an estimated 120 cases of sudden arrhythmic death in Kuala Lumpur per year. Our model prehospital system would save 7 of these. Trauma is a more serious problem in Malaysia. There were 467 traumatic deaths in Kuala Lumpur in 1990. 27 As discussed above, rapid transport to a hospital capable of providing critical surgical interventions is the key to saving those with treatable injuries.
DISCUSSION Our technique is easily modified by using other cities as models (Table 1). New York's data would result in $2.2 million per survivor, Seattle's in $340,000. These numbers are all approximations. Albuquerque and Seattle both use their fire departments for first response; this greatly reduces the cost of setting up a system but may increase long-term costs because fire vehicles are much more expensive to purchase and operate. The use of fire personnel will provide cost savings only if there are extra underused personnel available. The Kuala Lumpur fire department is currently staffed at a much lower level than are those of most US cities and is not willing to operate an ambulance system without additional resources. All three US cities also transport less severe injuries and patients between health care facilities. TABLE1. Estimated Cost and Survivors in Kuala Lumpur Based on Three US Cities
Population (106)* Size (km2)* First-response vehicles Transport vehicles Vehicles needed in Kuala Lumpur§ Survival rate (%) Survivors in Kuala Lumpurll Cost per survivor ($)¶
New York
Albuquerque
Seattle
7.3 782 1691" 561-
0.4 345 31 11
0.5 218 50:1: 17:~
66 1.4(ref8) 1.6 2,200,000
48 6 7 363,000
102 14(ref4) 16 338,000
*From Samrighett R (ed): World Almanac and Book of Facts 1994. World Almanac Books, Mahwah, NJ, 1994, pp 669, 671. -i-NewYork has a total of 225 emergency vehicles availableduring the evening shift, 75% were assigned as first-response vehicles based on Albuquerque and Seattle's numbers. :l:Seattle uses 33 fire engines, 11 fire trucks, and 6 aid cars for first response plus 5 (6 as of 1994) medic units and approximately 12 private ambulances for transportation. Personal communication from Lt Rick Newbrey, Seattle Fire Department, and Gregory Sim, Sheppard Life Transport. §This is calculated by multiplying the number of the reference city's first-response vehicles by the ratio of the reference city's size to Kuala Lumpur's size, performing a similar calculation using transport vehicles and population and adding the two resulting numbers. IJEstimated by multiplying the reference city's rate by Kuala Lumpur's 120 cardiac arrests. ¶Ambulances needed multiplied by $53,000 divided by estimated survivors, rounded to thousands. This is the estimated cost in Malaysia; the cost per ambulance in the US is several times higher.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 15, Number 6 • October 1997
Eliminating ambulances needed for transport of patients who are not seriously i11:Or injured would reduce costs, but only slightly, because Seattle dedicates only 12 private ambulances for this purpose and Albuquerque uses only 11 vehicles for all patient transports. Our analysis would be more clear if research had been performed in developed countries on the effects of ambulance care and its constituent parts (airway management, medication, stabilization, etc) before their use. Unfortunately, this was not done. Published literature about prehospital care has assumed that ambulance care is necessary, but ambulances are not the only way to transport patients to the hospital, and even when available may not always be the best way. Patients do get to the hospital in Malaysia despite the paucity of ambulances. Most seriously ill patients are driven by family or neighbors. Most seriously injured patients arrive by taxicab, police care, tow truck, or passerby. As near as we can tell from interviewing patients and drivers, the delay is usually small. Nonambulance transport has one major advantage: there is no need to activate the EMS system and have a vehicle drive to the patient. Although ambulances are somewhat faster than normal vehicles, in our experience this time savings is small. In almost all cases it would be faster to transport the victim directly rather than drive an ambulance to the patient and then to the hospital. The above analysis is conservative. Problems with access to telephones, mapping, house numbering, and signage make it unlikely that an 85% 6-minute response could be achieved without major expenses on those items. Currently in approximately 20% of calls in Kuala Lumpur the ambulance is unable to locate the patient. Traffic is far more congested in Kuala Lumpur than in most of the United States, and would delay many calls. There is little citizen cardiopulmonary resuscitation available. Patients resuscitated from cardiac arrest are expensive to care for, and we have disregarded in-hospital and home care costs. These factors would greatly increase the cost per successful intervention. We have also ignored patients with other illnesses that may benefit from prehospital treatment. Such cases undoubtedly exist, but it is clearly rare for such treatment to actually be life-saving. A larger flaw in our analysis is that we have ignored the comfort factor: it is certainly more pleasant to have one's femur fracture transported by ambulance than by taxicab. Lastly our analysis depends on the number of ambulances chosen. Although fewer would be less expensive and probably more costeffective, they would save fewer lives. The optimal number of ambulances is inevitably more a political than a medical decision.
CONCLUSION Development of a prehospital system for Kuala Lumpur based on a North American model would cost approximately $2.5 million per year. It might save seven lives, three marred by significant neurological damage. Less than four patients a year would be expected to survive 3 years. Attempting to analyze the effect of a major health care initiative is made more difficult by the existence of pre-
existing biases, plausible but unproven assumptions, and indirect effects. Prehospital care systems are expensive, and even in wealthy nations, resources spent on medical care may actually lower the overall health of the population. 31 In developing nations, the money might be better spent on occupational safety, schools, or better roadways. Developing countries might do well to consider alternative systems tailored to their own circumstances. One alternative might include mid-level providers on motorcycles supplemented by a limited number of ambulances. The authors thank Dr B. dagdev Singh, Medical advisor to the Malaysian Red Crescent Society, for his assistance and support.
REFERENCES 1. Jakobsson J, Rehnqvist N, Nyquist O: One year's experience of early defibrillation in Stockholm. J Int Med 1989;225:297-301 2. Stueven HA, Waite EM, Troiano P, et al: Prehospital cardiac arrest--a critical analysis of factors affecting survival. Resuscitation 1989;17:251-259 3. ValenzuelaTD, Spaite DW, Meislin HW, et al: Case and survival definitions in out-of-hospital cardiac arrest: effect on survival rate calculation. JAMA 1992;267:272-274 4. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med 1990;19:179186 5. Solomon NA: What are representative survival rates for out-ofhospital cardiac arrest? Arch Intern Med 1993; 153:1218-1221 6. Lewis RP, Stang JM, Warren JV: The role of paramedics in resuscitation of patients with prehospital cardiac arrest from coronary artery disease. Am J Emerg Med 1984;2:200-203 7. Kellermann AL, Hackman BB, Somes G, et al: Impact of first-responder defibrillation in an urban emergency medical services system. JAMA 1993;270:1708-1713 8. Lombardi G, Gallagher J, Gennis P: Outcome of out-of-hospital cardiac arrest in New York City: The pre-hospital arrest survival evaluation (PHASE) study. JAMA 1994;271:678-683 9. Becker LB, Han BH, Meyer PM, et al: Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med 1993;329:600-606 10. Hu S-C: Out-of-hospital cardiac arrest in an oriental metropolitan city. Am J Emerg Med 1994;12:491-494 11. Monsalve F, Rucabado L, Ruano M, et al: The neurologic effects of thiopental therapy after cardiac arrest. Intens Care Med 1987;13:244-248 12. Troiano P, Masaryk J, Stueven HA, et al: The effect of bystander CPR on neurologic outcome in survivors of prehospital cardiac arrests. Resuscitation 1989;17:91-98 13. Longstreth WT Jr: The neurologic sequelae of cardiac arrest. West J Med 1987;147:175-180 14. Roine RO, Kajaste S, Kaste M: Neuropsychological sequelae of cardiac arrest. JAMA 1993;269:237-242 15. Horton R: Science of sudden cardiac death. Lancet 1994;343: 1029-1030 16. Toro-Pedersen C, Birk-Mmadsen E, Pedersen A: The time factor in resuscitation initiated by ambulance drivers. Eur Heart J 1989; 10:555-557 17. Weaver WD, Fahrenbruch CE, Johnson DD, et al: Effect of epinephrine and lidocaine therapy on outcome after cardiac arrest due to ventricular fibrillation. Circulation 1990;82:2027-2034 18. Dean NC, Haug PJ, Hawker PJ: Effect of mobile paramedic units on outcome in patients with myocardial infarction. Ann Emerg Med 1988;17:1034-1041 19. Cummins RO, Graves JR, Larsen MP, et al: Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest. N Engl J Med 1993;328:1377-1382 20. Sampalis JS, Lavoie A, Williams JI, et al: Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993;34:252-261
HAUSWALD AND YEOH • PREHOSPITAL SYSTEM FOR A DEVELOPING COUNTRY
21. Cayten CG, Murphy JG, Stahl WM: Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more. J Trauma 1993;35:460-467 22. Mattox KL, Bickell W, Pepe PE, et al: Prospective MAST study in 911 patients. J Trauma 1989;29:1104-1112 23. Bickell WH, Wall MJ, Pepe PE, et al: Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109 24. O'Malley KF, Ross SE: The incidence of injury to the cervical spine in patients with craniocerebral injury. J Trauma 1988;28:14761478 25. Macdonald RL, Schwartz ML, Mirich D, et al: Diagnosis of cervical spine injury in motor vehicle crash victims: how many x-rays are enough? J Trauma 1990;30:392-397
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26. Wright SW, Robinson GG, Wright MB: Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation. Am J Emerg Med 1992;10:104-109 27. Vital Statistics, Peninsular Malaysia, Department of Statistics, Malaysia, Kuala Lumpur, 1989, 1990 28. Statistical Abstract of the United States: 1993 (113th edition). US Bureau of the Census, Washington, DC, 1993 29. Morbidity and Mortality Chartbook on Cardiovascular, Lung and Blood Diseases 1990. Bethesda, MD, National Heart, Lung, and Blood Institute; 1990 30. 1993 Heart and Stroke Facts Statistics, American Heart Association National Center, Dallas, Texas 31. Keeney RL: Decisions about life-threatening risks. N Engl J Med 1194;331:193-196
the real cost-benefit ratio for development of a prehospital emergency care system. Although the marginal value of adding specific therapies to a prehospital system is frequently analyzed, this is usually done in developed systems in which major costs, in particular personnel and ambulances, are already paid for. We used data available from fully developed prehospital systems and applied them to the demographic situation of Malaysia, a developing country with a rudimentary ambulance system, to estimate the desirability of developing a prehospital system similar to that used in most of North America.
METHODS Prehospital therapies that have been shown to decrease mortality were identified. A minimal prehospital system was designed to deliver these therapies in Malaysia. The cost of this system was calculated by taking the known cost of operating ambulances in Kuala Lumpur and modifying this to account for the additional equipment and personnel required. The potential benefit of these therapies was calculated by using statistics for the United States corrected for the demographic differences between the United States and Malaysia. Although almost any emergency therapy can be delivered outside the hospital, provided the prehospital personnel are adequately trained, we only analyzed therapies that are commonly used by paramedical personnel in North America. One disease process is responsible for almost all survivable prehospital cardiac arrests: the development of sudden arrhythmias, particularly ventricular fibrillation. One therapy is essential to benefit sudden arrhythmias: early defibrillation. The effectiveness of prehospital defibrillation is highly dependent on the underlying emergency medical services (EMS) system. Survival to hospital discharge rates of < 1% to 25% have been reported, H° although the largest cities reported 1% and 2%, partly because of difficulties in gaining access to the patients. 8,9The only report from a developing country reported 1.4%. 1° We chose 6% for our estimate because this is the overall survival to hospital discharge in Albuquerque, which we used for our primary comparison (data from other cities are also used for comparison in Table 1). Of surviving patients, approximately half have significant neurologica.[ injury. 7,11-14Half of survivors die within 3 years. 15 Survival is rare if defibrillation is delayed more than 5 to 10 minutes after arrest. 16We developed our model based on delivery of a defibrillator to 85% of patients within 6 minutes of system notification. Other therapies, such as advanced airway management, medications, and pacing, are much less effective than defibrillation. 1719 Although they may save a few patients with primary cardiac arrest or other medical problems, the cost of adding them to a system is small, and we chose to disregard both their cost and benefit. Prehospital care of trauma victims is more complex. For most injuries, definitive therapy requires the resources of an Emergency Department or Operating Room. Clearly, rapid transport to the
HAUSWALD AND YEOH • PREHOSPITAL SYSTEM FOR A DEVELOPING COUNTRY
hospital is more important than any pre-hospital therapy. 2°-21 Specific therapies that provide little or no measurable benefit include medical antishock trousers (MAST), 22intravenous fluids, 23 and medications. Early airway management may benefit patients with obstruction caused by facial injuries and perhaps those with severe brain injuries, but the former must be treated within minutes of the injury, and most of the latter will have poor outcomes despite the most aggressive care. Artificial ventilation is necessary for patients with high spinal lesions, but must be delivered within a few minutes of the accident. These patients rarely survive in any system. Review of medical records from Albuquerque showed no such patients surviving to hospital discharge during a 5-year period, No study documenting improved outcome in trauma patients because of airway management has been published. The additional cost of equipment and training needed for these therapies is small, and we ignored it in our analysis. Other therapies such spinal and other fracture immobilization may reduce short-or long-term morbidity but would rarely be expected to affect mortality. Although approximately 2% to 10% of seriously injured patients are thought to have unstable cervical spines, z4-26 it is not clear how many of these are affected by prehospital management. We were unable to find any studies that document a decrease in morbidity because of prehospital care. The systems we used for a primary comparison are quite different. Albuquerque, New Mexico, is a city of 385,000 covering 345 square kilometers. It is laid out in a grid pattern, all streets are mapped and signed, and house numbers are sequential by city block. Albuquerque currently uses a two-level priority response system (not all ambulances are available at all times), with approximately 11 transport ambulances and an additional 31 first-responding vehicles with defibrillators staffed by fire department emergency medical technicians (EMTs), These vehicles respond to approximately 35,000 emergency calls per year. This is comparable to other North American systems in terms of ambulances per survivor. Kuala Lumpur, Malaysia, is a city of 1.1 million and covers 243 square kilometers. It is laid out in isolated sections, and mapping and signage are incomplete. Kuata Lumpur currently has approximately 24 ambulances in service. Most ambulances are operated by factories or private hospitals for the transportation of their own patients. Only 8 ambulances are used primarily for emergency response within the federal district. Equipment costs are comparable between the United States and Malaysia because the equipment market is international in scope and import duties into Malaysia are only 3% for medical equipment. Personnel and therefore maintenance is less expensive in Malaysia. The Red Crescent Society operates eight minivan-based ambulances 24 hours per day on a budget of $367,000 (all figures are in US dollars as of 1993). This includes personnel, ambulance purchase, and maintenance, but only minimal equipment. Adding semiautomatic defibrillators and additional equipment, a modem dispatch system, and a modest pay raise commensurate with the additional training would increase this by approximately 15% to $53,000 per ambulance. We estimate that a prehospital system similar to Albuquerque's would require 22 first-response vehicles based on Kuala Lumpur's size plus 26 ambulances based on its population. This would cost $2.5 million per year.
RESULTS Malaysia has a low incidence of coronary artery disease probably primarily because of its population's youthful average age; in 1990, 352 of the 4,779 deaths in Kuala Lumpur were caused by myocardial infarcts (7.4%). 27 In the United States, approximately one quarter of all deaths are caused by ischemic heart disease, 28 half of these are sudden arrhythmic deaths, 29 and two thirds of the sudden deaths occur out of hospital. 3° The latter numbers are not particu-
601
laxly dependent on the EMS system. Most cases of sudden death occur before help can be sought, and even in the United States where much effort has been spent on educating the public on the symptoms of an infarction, the average patient delays 2 hours before notifying the EMS system. 3° Extrapolating these statistics produces an estimated 120 cases of sudden arrhythmic death in Kuala Lumpur per year. Our model prehospital system would save 7 of these. Trauma is a more serious problem in Malaysia. There were 467 traumatic deaths in Kuala Lumpur in 1990. 27 As discussed above, rapid transport to a hospital capable of providing critical surgical interventions is the key to saving those with treatable injuries.
DISCUSSION Our technique is easily modified by using other cities as models (Table 1). New York's data would result in $2.2 million per survivor, Seattle's in $340,000. These numbers are all approximations. Albuquerque and Seattle both use their fire departments for first response; this greatly reduces the cost of setting up a system but may increase long-term costs because fire vehicles are much more expensive to purchase and operate. The use of fire personnel will provide cost savings only if there are extra underused personnel available. The Kuala Lumpur fire department is currently staffed at a much lower level than are those of most US cities and is not willing to operate an ambulance system without additional resources. All three US cities also transport less severe injuries and patients between health care facilities. TABLE1. Estimated Cost and Survivors in Kuala Lumpur Based on Three US Cities
Population (106)* Size (km2)* First-response vehicles Transport vehicles Vehicles needed in Kuala Lumpur§ Survival rate (%) Survivors in Kuala Lumpurll Cost per survivor ($)¶
New York
Albuquerque
Seattle
7.3 782 1691" 561-
0.4 345 31 11
0.5 218 50:1: 17:~
66 1.4(ref8) 1.6 2,200,000
48 6 7 363,000
102 14(ref4) 16 338,000
*From Samrighett R (ed): World Almanac and Book of Facts 1994. World Almanac Books, Mahwah, NJ, 1994, pp 669, 671. -i-NewYork has a total of 225 emergency vehicles availableduring the evening shift, 75% were assigned as first-response vehicles based on Albuquerque and Seattle's numbers. :l:Seattle uses 33 fire engines, 11 fire trucks, and 6 aid cars for first response plus 5 (6 as of 1994) medic units and approximately 12 private ambulances for transportation. Personal communication from Lt Rick Newbrey, Seattle Fire Department, and Gregory Sim, Sheppard Life Transport. §This is calculated by multiplying the number of the reference city's first-response vehicles by the ratio of the reference city's size to Kuala Lumpur's size, performing a similar calculation using transport vehicles and population and adding the two resulting numbers. IJEstimated by multiplying the reference city's rate by Kuala Lumpur's 120 cardiac arrests. ¶Ambulances needed multiplied by $53,000 divided by estimated survivors, rounded to thousands. This is the estimated cost in Malaysia; the cost per ambulance in the US is several times higher.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 15, Number 6 • October 1997
Eliminating ambulances needed for transport of patients who are not seriously i11:Or injured would reduce costs, but only slightly, because Seattle dedicates only 12 private ambulances for this purpose and Albuquerque uses only 11 vehicles for all patient transports. Our analysis would be more clear if research had been performed in developed countries on the effects of ambulance care and its constituent parts (airway management, medication, stabilization, etc) before their use. Unfortunately, this was not done. Published literature about prehospital care has assumed that ambulance care is necessary, but ambulances are not the only way to transport patients to the hospital, and even when available may not always be the best way. Patients do get to the hospital in Malaysia despite the paucity of ambulances. Most seriously ill patients are driven by family or neighbors. Most seriously injured patients arrive by taxicab, police care, tow truck, or passerby. As near as we can tell from interviewing patients and drivers, the delay is usually small. Nonambulance transport has one major advantage: there is no need to activate the EMS system and have a vehicle drive to the patient. Although ambulances are somewhat faster than normal vehicles, in our experience this time savings is small. In almost all cases it would be faster to transport the victim directly rather than drive an ambulance to the patient and then to the hospital. The above analysis is conservative. Problems with access to telephones, mapping, house numbering, and signage make it unlikely that an 85% 6-minute response could be achieved without major expenses on those items. Currently in approximately 20% of calls in Kuala Lumpur the ambulance is unable to locate the patient. Traffic is far more congested in Kuala Lumpur than in most of the United States, and would delay many calls. There is little citizen cardiopulmonary resuscitation available. Patients resuscitated from cardiac arrest are expensive to care for, and we have disregarded in-hospital and home care costs. These factors would greatly increase the cost per successful intervention. We have also ignored patients with other illnesses that may benefit from prehospital treatment. Such cases undoubtedly exist, but it is clearly rare for such treatment to actually be life-saving. A larger flaw in our analysis is that we have ignored the comfort factor: it is certainly more pleasant to have one's femur fracture transported by ambulance than by taxicab. Lastly our analysis depends on the number of ambulances chosen. Although fewer would be less expensive and probably more costeffective, they would save fewer lives. The optimal number of ambulances is inevitably more a political than a medical decision.
CONCLUSION Development of a prehospital system for Kuala Lumpur based on a North American model would cost approximately $2.5 million per year. It might save seven lives, three marred by significant neurological damage. Less than four patients a year would be expected to survive 3 years. Attempting to analyze the effect of a major health care initiative is made more difficult by the existence of pre-
existing biases, plausible but unproven assumptions, and indirect effects. Prehospital care systems are expensive, and even in wealthy nations, resources spent on medical care may actually lower the overall health of the population. 31 In developing nations, the money might be better spent on occupational safety, schools, or better roadways. Developing countries might do well to consider alternative systems tailored to their own circumstances. One alternative might include mid-level providers on motorcycles supplemented by a limited number of ambulances. The authors thank Dr B. dagdev Singh, Medical advisor to the Malaysian Red Crescent Society, for his assistance and support.
REFERENCES 1. Jakobsson J, Rehnqvist N, Nyquist O: One year's experience of early defibrillation in Stockholm. J Int Med 1989;225:297-301 2. Stueven HA, Waite EM, Troiano P, et al: Prehospital cardiac arrest--a critical analysis of factors affecting survival. Resuscitation 1989;17:251-259 3. ValenzuelaTD, Spaite DW, Meislin HW, et al: Case and survival definitions in out-of-hospital cardiac arrest: effect on survival rate calculation. JAMA 1992;267:272-274 4. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med 1990;19:179186 5. Solomon NA: What are representative survival rates for out-ofhospital cardiac arrest? Arch Intern Med 1993; 153:1218-1221 6. Lewis RP, Stang JM, Warren JV: The role of paramedics in resuscitation of patients with prehospital cardiac arrest from coronary artery disease. Am J Emerg Med 1984;2:200-203 7. Kellermann AL, Hackman BB, Somes G, et al: Impact of first-responder defibrillation in an urban emergency medical services system. JAMA 1993;270:1708-1713 8. Lombardi G, Gallagher J, Gennis P: Outcome of out-of-hospital cardiac arrest in New York City: The pre-hospital arrest survival evaluation (PHASE) study. JAMA 1994;271:678-683 9. Becker LB, Han BH, Meyer PM, et al: Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med 1993;329:600-606 10. Hu S-C: Out-of-hospital cardiac arrest in an oriental metropolitan city. Am J Emerg Med 1994;12:491-494 11. Monsalve F, Rucabado L, Ruano M, et al: The neurologic effects of thiopental therapy after cardiac arrest. Intens Care Med 1987;13:244-248 12. Troiano P, Masaryk J, Stueven HA, et al: The effect of bystander CPR on neurologic outcome in survivors of prehospital cardiac arrests. Resuscitation 1989;17:91-98 13. Longstreth WT Jr: The neurologic sequelae of cardiac arrest. West J Med 1987;147:175-180 14. Roine RO, Kajaste S, Kaste M: Neuropsychological sequelae of cardiac arrest. JAMA 1993;269:237-242 15. Horton R: Science of sudden cardiac death. Lancet 1994;343: 1029-1030 16. Toro-Pedersen C, Birk-Mmadsen E, Pedersen A: The time factor in resuscitation initiated by ambulance drivers. Eur Heart J 1989; 10:555-557 17. Weaver WD, Fahrenbruch CE, Johnson DD, et al: Effect of epinephrine and lidocaine therapy on outcome after cardiac arrest due to ventricular fibrillation. Circulation 1990;82:2027-2034 18. Dean NC, Haug PJ, Hawker PJ: Effect of mobile paramedic units on outcome in patients with myocardial infarction. Ann Emerg Med 1988;17:1034-1041 19. Cummins RO, Graves JR, Larsen MP, et al: Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest. N Engl J Med 1993;328:1377-1382 20. Sampalis JS, Lavoie A, Williams JI, et al: Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993;34:252-261
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21. Cayten CG, Murphy JG, Stahl WM: Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more. J Trauma 1993;35:460-467 22. Mattox KL, Bickell W, Pepe PE, et al: Prospective MAST study in 911 patients. J Trauma 1989;29:1104-1112 23. Bickell WH, Wall MJ, Pepe PE, et al: Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109 24. O'Malley KF, Ross SE: The incidence of injury to the cervical spine in patients with craniocerebral injury. J Trauma 1988;28:14761478 25. Macdonald RL, Schwartz ML, Mirich D, et al: Diagnosis of cervical spine injury in motor vehicle crash victims: how many x-rays are enough? J Trauma 1990;30:392-397
603
26. Wright SW, Robinson GG, Wright MB: Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation. Am J Emerg Med 1992;10:104-109 27. Vital Statistics, Peninsular Malaysia, Department of Statistics, Malaysia, Kuala Lumpur, 1989, 1990 28. Statistical Abstract of the United States: 1993 (113th edition). US Bureau of the Census, Washington, DC, 1993 29. Morbidity and Mortality Chartbook on Cardiovascular, Lung and Blood Diseases 1990. Bethesda, MD, National Heart, Lung, and Blood Institute; 1990 30. 1993 Heart and Stroke Facts Statistics, American Heart Association National Center, Dallas, Texas 31. Keeney RL: Decisions about life-threatening risks. N Engl J Med 1194;331:193-196