K EME N TE R IA N K ES I HA TA N MA LA YS IA
Office of Deputy Director General of Health (Medical), Ministry Of Health Malaysia
RUJ. TUAN :
RUJ. KAMI : KKM87/P1/28/3JLD2(59)
TARIKH : 24 APRIL 2008
YBhg Dato’/Datin/Tuan/Puan,
Oleh itu, bagi memastikan langkah ini dilaksanakan, Program Perubatan sedang berusaha
untuk mendokumentasi polisi operasi perkhidmatan-perkhidmatan perubatan. Bersama-
sama ini disertakan naskah dokumen polisi – Anaesthesia and Intensive Care Service;
Operational Policy, yang telah berjaya dirangka oleh Bahagian Perkembangan Perubatan
dengan kerjasama pakar-pakar anaesthesia dan rawatan rapi. Dokumen tersebut
merangkumi aspek-aspek penting di dalam operasi perkhidmatan termasuk pengurusan
sumber manusia, pembangunan infrastruktur, struktur organisasi, kualiti, pengurusan
pesakit, etika dan lain-lain berkaitan urustadbir klinikal. Dokumen tersebut adalah relevan
untuk dipraktikkan di semua kategori hospital iaitu di hospital negeri, hospital pakar dan
hospital tanpa pakar.
Diharap pihak YBhg Dato’/Datin/Tuan/Puan dapat memastikan segala perkara yang
diperuntukkan di dalam dokumen polisi tersebut dilaksanakan di peringkat negeri/hospital
masing-masing. Naskah buku tersebut juga hendaklah diedarkan kepada semua pengarah
hospital, ketua-ketua jabatan yang berkenaan dan diletakkan di kawasan-kawasan tertentu
seperti dewan bedah dan unit rawatan rapi sebagai rujukan anggota perubatan. Semua
anggota perubatan di dalam Jabatan Anaesthesia dan Rawatan Rapi termasuk anggota yang
baru juga diminta untuk meneliti dan melaksanakan dokumen tersebut.
S.k
- Ketua Pengarah Kesihatan Malaysia
- Pengarah Perkembangan Perubatan
- Penasihat Kebangsaan Perkhidmatan Anaesthesia dan Rawatan Rapi
MEDICAL DEVELOPMENT DIVISION,
MINISTRY OF HEALTH MALAYSIA
ANAESTHESIA AND INTENSIVE CARE SERVICE
OPERATIONAL POLICY
This policy was developed by the Surgical and Emergency Services Unit, Medical Services
Development Section of Medical Development Division and the Drafting Committee of Operational
Policy of Anaesthesia and Intensive Care Service.
Medical Development Division would like to acknowledge the contributions of the following groups
and individuals towards the development of this document;
Dato’ Dr Noorimi Hj Morad, the former Deputy Director General of Health (Medical Services) for her
leadership and guidance. Her commitment, dedication and thoughtfulness is strongly admired.
Dr Ng Siew Hian and the Drafting Committee on Operational Policy of Anaesthesia and Intensive
Care Service for the continuing support and dedication. Their vast experience and professionalism
have facilitated the Division in developing this document.
Special gratitude to the National Advisors of Surgery, Orthopaedic, Medicine, Paediatric, Obstetrics
and Gynaecology Services and other relevant parties for the constructive comments on the draft
policy.
CONTENT
FOREWORD
Director General of Health Malaysia 3
Deputy Director General of Health (Medical) 4
National Advisor for Anaesthesia and Intensive Care Service 5
ARTICLES
1 Introduction 7
2 Objectives of Service 8
3 Scope of Service 9
4 Components of Service 10
5 Organisation 12
6 General Statement 17
7 Peri-operative Anaesthesia Service
7.1 Anaesthetic Clinic 22
7.2 General Anaesthesia Service in the Operating Theatre 24
7.3 Anaesthesia Service outside the Operating Theatre 28
8 Subspecialty Anaesthesia Service
8.1 Cardiothoracic Anaesthesia and Perfusion Service 30
8.2 Paediatric Anaesthesia Service 33
8.3 Neuro-anaesthesia Service 37
8.4 Obstetric Anesthesia Service 39
8.5 Day-Care Anaesthesia Service 41
9 Intensive Care Service 42
10 Pain Management Service
10.1 Acute Pain Service 51
10.2 Obstetric Analgesia Service 53
10.3 Chronic Pain Service 55
11 Training and Education 57
12 Quality and Research 58
13 Whole Hospital Policy 60
APPENDIX
i Terms Of Reference For Department Committees 64
ii Guide On Patient Safety In The Department Of Anaesthesia And Intensive Care 66
iii Guide On Medication Safety In The Department Of Anaesthesia And Intensive Care 68
REFERENCE 94
LIST OF CHARTS AND TABLES
Despite the many achievements of our healthcare delivery system in the past
and present, an increasingly educated public continues to expect even better
services from our hospitals. Clearly, there is still much room for
improvement. Better methods and processes for the delivery of hospital-
based services have to be formulated and implemented, and we should have
the determination and courage to put planned strategies into action. We also
need to ensure that proper systems are put in place in our hospitals that are
acceptable, evidence-based, outcome-oriented, quality driven, practical, and
above all suit the needs and interests of our patients. Having a well-
documented Operational Policy for a clinical discipline like this will help to
ensure that services are executed efficiently, utilising existing resources.
Having documents like this shall be among our strategies to improve the
medical services, apart from measures like infrastructural and human capital
development.
Anaesthesia and intensive care service is one of the main medical services
provided by our Ministry of Health hospitals by virtue of its capacity to
support other clinical disciplines and to provide adequate and appropriate
care for critically ill patients. Advancement of surgery, increasing workload
and higher public expectations are among the factors that have made the
provision of anaesthesia one of the major challenges in developing hospital
services in the country. Furthermore, lack of intensive care beds in public
hospitals and manpower constraints have posed a major problem that need
to be addressed prudently in order to ensure better, more accessible and
higher quality medical care in the future.
1.1. Anaesthesia and Intensive Care service are among the major
clinical specialty services provided by the Ministry of Health
hospitals.
1.3. As the biggest health care provider in the county, hospitals in the
Ministry of Health play a leading role in the development and
provision of anaesthetic and intensive care service in the country.
1.7. The document shall be reviewed and updated every three years or
when the need arises.
3.2. The department also provides care for the critically ill surgical or
medical patients, requiring intensive monitoring and intervention
or advanced life support.
4.2.3. Neuro-anaesthesia
Anaesthetic clinic √ √ - -
2 Refer to appendix viii; Level Of Intensive Care Units In Ministry Of Health’s Hospitals, page 82
5.2. The Head of Anaesthesia and Intensive Care Service serves as the
National Advisor to the Ministry of Health on all matters
pertaining to the service. The specific functions of the National
Advisor of Anaesthesia and Intensive Care Service are listed in
appendix ix.
Specialist
Nursing Sister
Attendant Attendant
Chart 1; Organisation Chart (by Position) of the Department of Anaesthesia and Intensive Care
PAIN MANAGEMENT UNIT PERI-OPERATIVE ANAESTHESIA UNIT SUBSPECIALTY ANAESTHESIA UNIT INTENSIVE CARE UNIT
Anaesthesia in the
Chronic P a i n Operating Theatre
Chart 2; Organisation Chart (by Function) of the Department of Anaesthesia and Intensive Care
6.3. In rural East Malaysia, every effort shall be made to ensure that a
doctor based service is achieved within a predetermined time
frame.
6.5. All critically ill patients with reversible conditions and in whom
reasonable functional status may be restored, shall be cared for in
the intensive care unit. Managing patients on mechanical
ventilators in the general ward shall be discouraged.
6.6. Referral of cases from non specialist hospitals shall be made to the
nearest specialist hospital with the appropriate level of care.
5Refer to appendix ii; Guide On Patient Safety In The Department Of Anaesthesia And
Intensive Care, page 66
6Refer to appendix iii; Guide on Medication Safety in the Department of Anaesthesia and
Intensive Care, page 68
7 Refer to appendix iv; List of Recommended Equipments for Various Facilities, page 70
6.16. A monthly on-call roster with all contact numbers shall be made
available to other departments and on-call team shall be
contactable at all times by telephone or pager.
6.20. All anaesthetic departments shall comply with the standards set
by the Malaysian Society for Quality in Health (MSQH) or Joint
Commission International (JCI) and seek accreditation status as
part of the hospital wide initiative. Departments in major
hospitals are encouraged to work towards accreditation by the
Australian and New Zealand College of Anaesthetists (ANZCA).
7.2.11. All equipment of more than ten years shall be phased out
in stages to ensure safety and uninterrupted service.
9.1. The main objective of the Intensive Care Service is to provide the
highest standard of care possible using evidence-based practice in
all critically ill patients who require intensive monitoring or
advanced life support in a safe and comfortable environment for
the patients and their relatives.
9.2. The Intensive Care Unit shall provide the level of care appropriate
to the size and overall function of the hospital. The level of care
shall also be determined by the facilities and expertise available in
the unit 10.
9.3. There shall preferably be only a single Intensive Care Unit that
caters for all patients from all medical and surgical specialties in
the hospital. However, in speciality based institutes, dedicated
intensive care units catering for such services may be established.
9.4. For the continuum and high quality care of the critically ill
patients, high dependency patients shall be cared for in an
integrated intensive care/high dependency unit. Similarly,
patients requiring stepped down care following intensive care
shall be cared for in this integrated unit.
10Refer to appendix viii; Levels of Intensive Care Units in Ministry of Health hospitals, page
82
9.10.9. The Intensive Care Unit doctor shall brief the immediate
family of the patient’s condition, management plan,
possible complications and expected outcome on admission
to the unit. The immediate relative shall also be updated
regularly on the patient’s progress. Enquires by other
relatives or friends shall be directed to the identified
immediate relative.
12Refer to Management Protocol in Intensive Care Unit. Admission, Discharge Criteria and
Triage, Management Protocol in Intensive Care Unit. Medical Development Division (2006)
14Refer to appendix ii; Guide On Patient Safety In The Department Of Anaesthesia And
Intensive Care, page 66
9.10.19. All staff shall observe strict hand hygiene and standard
precaution measures during patient care.
15Refer to Dellinger RP, Cartlet IM, Masur H, et al. Guidelines for the management of
severe sepsis and septic shock. Intensive Care Medicine (2004) 30:536-555
9.10.28. All staff shall care for the dying patients in the same
compassionate and caring manner as they would care for
patients who are expected to survive. Physical, emotional
and spiritual needs shall be provided to the dying patients
and their relatives to the best of one’s ability.
Refer To Warren J, Fromm RE, Orr RA, Et Al. Guidelines for the Inter-Hospital and Intra-
16
Hospital Transport of Critically Ill Patients. Critical Care Medicine (2004); 32:256-262
9.10.33. The Intensive Care Service shall be prepared for any surge
in demand such as during mass casualties or disease
outbreaks e.g. pandemic avian influenza. For mass
casualties, local hospital disaster plans shall be adhered to.
In the case of pandemic avian influenza outbreak, the
management shall be guided by the Intensive Care
Preparedness for Avian Influenza Pandemic (Ministry of
Health Malaysia 2006).
9.10.37. The unit shall ensure visitors adhere to the visiting protocol
and visiting hours.
9.11.2. The area for each bed shall be sufficient to allow easy access
to the patient and to allow the deployment of equipment
needed to manage the patient appropriately. It shall also
take into account the risk of cross infection.
Committee of the American College of Critical Care Medicine & Society of Critical Care
Medicine
18 Refer to appendix iv; List Of Recommended Equipment For Various Facilities, page 70
10.1.3.3. The APS team shall review all patients at least twice a
day.
10.3.2.5. The chronic pain management clinic shall have all the
appropriate facilities and equipment for a full
assessment of chronic pain patients.
11.1. The department shall define the level of knowledge, skills and
training requirements for all its personnel.
11.2. A written orientation programme shall be used to introduce new
staff to the relevant aspects of the facilities and prepare them for
their roles and responsibilities.
11.3. The staff shall have access to appropriate educational programme
to maintain and augment their professional competency.
Participation in theses educational or training activities shall be
documented.
11.4. All staff is required to participate in the Ministry’s e-CPD
programme.
11.5. The department shall facilitate staff to attend relevant educational
programmes conducted by professional groups, societies and
educational institutes.
19Refer to appendix xi; Key Performance Indicator for the Department of Anaesthesia and
Intensive Care, page 91
12.2. Research
13.2.1. All staff shall observe proper hand hygiene at all times.
There shall be adequate facilities to support this practice.
A. Management Committee
D. Safety Committee
4. Two staff shall counter-check the correct drug, dose, dilution and
route prior to administration of high alert medications (digoxin,
heparin, potassium chloride, insulin, magnesium sulphate and
epidural/regional block infusions). Therapeutic levels shall be
monitored where applicable.
10. All multi-dose vials and ampoules shall be swabbed with alcohol
wipes prior to drawing out the contents
13. Patient shall be monitored for drug effectiveness and adverse effects.
All adverse effects shall be documented into the patients’ records,
informed later to the patient (or relatives) and reported to the
pharmacy via the adverse drug reaction (ADR) format.
14. All medication errors and near misses shall be reported using the
Ministry of Health standardized form (Critical Incident Form) for
education and prevention as part of the patient safety program.
A. Anaesthesia
B. Recovery Room
D. Pain Management
E. Subspecialty Services
2. The patients and /or family shall be given a full explanation of the
anaesthetic or procedure including its risks and benefits and other available
alternatives. A written informed consent shall be obtained after the
discussion
1. Injection Adrenaline
2. Injection Atropine
3. Injection Hydrocortisone
4. Injection Lignocaine
5. Injection Heparinised saline
6. Injection Dopamine
7. Injection Ephedrine
8. Injection Dexamethasone
9. Injection Sodium bicarbonate
10. Injection Neostigmine
11. Injection Propofol
12. Injection Thiopentone
13. Injection Ketamine
14. Injection Etomidate
15. Injection Suxamethonium
16. Injection Atracurium
17. Injection Rocuronium
18. Injection Distilled water
1. Injection Digoxin
2. Injection Phenylephrine
3. Injection Sodium glycopyrollate
4. Injection Ondansetron / Granisetron
5. Injection Hyoscine butylbromide
1. Injection Adrenaline
2. Injection Atropine
3. Injection Adenosine
4. Injection 50% Dextrose
5. Injection Naloxone
6. Injection Flumezenil
7. Injection Calcium gluconate
1. Injection Amiodarone
2. Injection Phenytoin
3. Injection Aminophylline
4. Injection Terbutaline/Salbutamol
5. Injection Magnesium sulphate
6. Injection Potassium Chloride
7. Injection Calcium Chloride
8. Injection Potassium dihydrogen phosphate
9. Injection Dobutamine
1. Injection Propofol
2. Injection Etomidate
3. Injection Suxamethonium
4. Injection Atracurium
5. Injection Rocuronium
6. Injection Esmolol
7. Local anaesthetic isobaric Bupivacaine
8. Local anaesthetic hyperbaric Bupivacaine
9. Local anaesthetic Ropivacaine
10. Injection Noradrenaline
Intensive care units (ICU) are specialized areas where critically ill patients
requiring advanced life support are managed by a team of specially trained
doctors and nurses. The ICU is an integral part of an acute care hospital
providing care for patients with medical diseases or following trauma or
surgery. Intensive care service in the Ministry of Health hospitals is provided
by the Department of Anaesthesia and Intensive Care.
Hospitals have become larger and more specialized, expectation of patients has
increased and society is more aware of their rights. In the last ten years, the
demand for intensive care beds far exceeded its supply and this has resulted in
severe shortage of ICU beds in the Ministry of Health (MOH) hospitals. Based
on a survey in 2003 (National Audit on Adult Intensive Care Units), the number
of ICU beds in MOH hospitals was 222 or 43% of the total number of ICU beds
in Malaysia. At a total of 509 beds in the whole country, Malaysia has 2 ICU
beds per 100,000 populations as compared to 24 per 100,000 in US, 7 per 100,000
in Australia and Singapore. ICU beds in MOH state hospitals comprise 1% of
the total hospital beds. This is still below the figure of around 2.6% in the
United Kingdom, 4.1% in Denmark and 10% in the United States.
Each year, more than five thousand patients in MOH state hospitals are denied
ICU admissions due to the unavailability of beds in the ICU. This figure far
exceeded the acceptable refusal rate of intensive care admission, which is about
5% (Intensive Care Working Group of the Clinical Resource Efficiency Support
Team (CREST) UK 1993).
The number of beds needed, will depend on a variety of factors; among which
are expected length of stay, occupancy levels, and the demand for intensive care
expected from the population.
The recommended bed occupancy rate (BOR) for an ICU is 70%. This should
ensure that units could respond to emergencies and that patients would be less
likely to be refused admission.
Estimation of intensive care beds:
Basic Number of Beds (X)
= Annual hospital admissions x rate of demand x Average length of stay
365 x ideal occupancy
Assuming a Poisson distribution, the number of beds required to accept 95% of
referrals at all times: = X + (1.64 x √X)
The ratio of intensive care to high dependency beds will be based the ratio of
intensive care days to high dependency days. In the example above, if the ratio
is 3:2, therefore, the anticipated bed requirements will be 20 intensive care beds
and 12 high dependency beds.
The Joint Faculty of Intensive Care Medicine, Australia and New Zealand in its
Policy Document Review 2003 on Minimum Standards for Intensive Care
recommended that a Paediatric ICU should have a minimum of 300 admissions
per year to ensure sufficient clinical workload to maintain clinical expertise.
Level 1 -
This is equivalent to the ‘high dependency unit’ or ‘acute care ward’ and shall
be made available in all district hospitals without anaesthetist. The unit shall
have 4-6 beds and shall be capable of providing intensive monitoring and basic
intensive care e.g. oxygen therapy and inotropic support but not mechanical
ventilation. Nurse to patient ratio shall be 1: 2 - 3 patients.
Level 2 -
This shall be located in district hospitals with anaesthetists capable of providing
intensive care. The number of beds shall be 6 - 10 and the unit shall be capable
of providing mechanical ventilation. Nurse to patient ratio shall be 1:2 for non-
ventilated patients and 1:1 for ventilated patients.
Level 3 -
All state and major specialist hospitals shall have Level 3 Intensive Care Units
with facilities for multiple organ support e.g. mechanical ventilation and renal
replacement. Nurse to patient ratio shall be 1:1 or more in complex cases. The
unit shall operate as a ‘closed unit’ directed by an intensivist or an anaesthetist
with special interest in intensive care. The number of beds shall range from 16 to
35, or approximately 3% - 5% of acute hospital beds depending on the services
provided by the hospital. The unit shall be a mixed medical and surgical unit
The main function of the National Advisor of Anaesthesia and Intensive Care is
to advise the Ministry of Health in matters pertaining to Anaesthesia, Intensive
Care and Pain management on manpower, training, equipment, budget and
development. The National Advisor coordinates with the heads of department
in the implementation of government policies to achieve the Ministry of
Health’s vision and missions.
Specific functions:
B. Head of Department
Administrative
Clinical
C. Specialist
Administrative
D. Medical Officer
Administrative
Clinical
A. Specialist
Management
Research methodology and biostatistics
Quality assurance
Professional conferences
B. Medical Officer
Perfusionist course
Acute Pain Service
Paediatric Advanced Life Support
Dr Teng Seng Chong, Senior Deputy Director Ipoh (Main document and Pain service)
of Department of Anaesthesia and Intensive Anaesthesia and Intensive Care, Hospital Sg.
Members
Dr. Mary Cardosa, Consultant Anaesthetist
Datin Dr. V. Sivasakthi, Head of Department and Pain Specialist, Hospital Selayang (Pain
Dr. Aisai b. Abdul Rahman, Head of Hospital Kuala Lumpur, (Proof reading)
Mr. Harjit Singh, National Advisor of Surgical Mr Abdul Rahman Ismail National Advisor of
Service, Head of Department and Senior Cardiothoracic Service, Head of
Consultant Surgeon, Department of Cardiothoracic Department, Hospital
Hepatopancreatobiliary, Hospital Selayang Sultanah Aminah Johor Bahru
Association of Anaesthetists of Great Britain, July 1999. Information and Consent for
Anaesthesia.
Australia and New Zealand College of Anaesthesiologists, 1998. P28. Policy on Infection
Control.
Australia and New Zealand College of Anaesthesiologists, 2003, PS 39. Minimum Standards
for Intra Hospital Transport of Ill Patients.
Australia and New Zealand College of Anaesthesiologists. 2003, PS8. Guidelines on the
Assistant for the Anaesthetist.
Medical Development Division, Ministry of Health Malaysia, June 2007. National Organ,
Tissue and Cell Transplantation Policy.
Ministry of Health 2006. Intensive Care Preparedness for Avian Influenza Pandemic.
Ministry of Health Malaysia, 2004. Standard Operating Procedure for Potential Infectious
Disease.
Ministry of Health Malaysia, 2006. Management Protocols in ICU 2006: ICU Management
Protocol No. 1; Admission, Discharge Criteria and Triage.
Occupational Health Unit, Ministry of Health Malaysia 2002. Pocket Guidelines for
Standard Precaution.