Critical Care: Current challenges and the need of the hour
Critical care is a principal stopover for a patient enroute to recovery and healing. While some diseases and health conditions by their very nature necessitate instant admission to critical care, in some not-so-serious conditions too when deteriorate, a patient may have to go for critical care. In short, critical care is a bulwark against life-threatening injuries and illnesses.
Over the years, even as critical care medicine has evolved as a specialty involved in assessment, resuscitation and management of critically ill patients, it essentially encompasses a range of products and services meant to deliver care to a patient in times of life-threatening emergencies. And like most things today, technology has come to play an inevitable role in offering new and advanced machines and equipment as well as in the way care is delivered to patients in emergency situations. At a time when Covid-19has emerged as an unprecedented public health emergency calling for critical care attention for a substantial number of patients, the entire critical care ecosystem has been tested to the limits.
What are some of those challenges and what can be done to address them?
Inadequacy of ICU beds and disparity in distribution remains a challenge
The ongoing pandemic has already demonstrated the shortage of ICU beds and associated paraphernalia in the country. In the first year of the pandemic, one research estimated that India had approximately 95 thousand ICU beds and 48 thousand ventilators with the majority being concentrated within seven states only. Another research highlighted the disparity between states as well as big cities and urban areas and the rural hinterland. By the end of last year, in government’s assessment, the country possessed 1.39 lakh ICU beds and 24,000 paediatric ICU beds.
Incomplete ICUs with insufficient equipment and devices
Even when there are ICUs present in a facility, they are not sufficiently furnished with all the accompanying paraphernalia and equipment. The Indian Society of Critical Care Medicine guidelines on planning and designing of ICUs has provided for three levels of ICU/HDU units in different hospitals depending on the number of beds that a facility has. For instance, under Level I for those facilities having up to 50 beds or district hospitals and CHCs having up to 100 beds, there should be 6 to 8 ICU beds accompanied with the ability to perform cardiopulmonary resuscitation including intubation, short-term cardio-respiratory support including, non-invasive ventilation, and defibrillation. While having access to ABG facility, they should also have syringe pumps/infusion pumps, apart from multipara monitors with SPO2, HR and ECG, NIBP and temperature facility. Similarly, more functionalities and presence of advanced equipment have been mandated for the higher Level II (those with up to 100 to 150 beds and Level III (those with over 150 beds including medical colleges and corporate hospitals) facilities. However, more focus is needed towards the emergency care facilities especially in non-metro cities.
Quality of critical care equipment and manpower
Along with the problem of inadequacy of ICU beds and related resource shortage, quality of ICU care too has been a challenge, both in terms of equipment and human resources. In recent times during Covid, there were several instances reported in the media of shortage or low quality ventilators. Moreover, lack of optimum use of the ventilators is also a matter of concern.
What can we do to address these challenges?
First, we need to focus on augmenting the domestic production of ICU equipment and machines. The government has made provisions through PLI schemes and clustering facilities for medical devices, equipment related to critical care also needs attention.
Second, the healthcare facilities must be regularly inspected and monitored for housing mandatory ICU beds and related equipment. The ratio of ICU beds to number of over-all hospital bedside 1:4 ratio must be followed and adhered to.
Third, similarly, it must also be ensured that all facilities have allocated mandatory manpower for critical care commensurate with their size and the footfall.
Fourth, there must be regular quality audit of these critical care facilities and their machines and equipment by authorities.
Fifth, the health personnel including doctors, nurses and paramedics involved in critical care must be trained to handle equipment and machines in the ICUs.
Sixth, critical care medicine as a part of the curriculum must be extended to more and more of medical schools in order to prepare a sufficient pool of specialists within the country.
Seventh, the hospital administration must inculcate a culture of best practices for ICU and critical care. For instance, sometimes, corrugated tubes – which are supposed to be single use device – are reused on patients. This should be dealt with sternly.
Eighth, while the standards and certification systems for medical devices stipulated by developed countries’ regulatory authorities are okay, we need to develop our own certification systems relevant to our own value chains and the strengths and weaknesses inherent in those value chains.
