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India's critical care facilities at critical juncture
Falaknaaz Syed - Mumbai
Shortage of ICU beds in hospitals across the country, dearth
of qualified intensivists, non-compliance in following
protocols in critical care and the government's inability
to meet the increasing demand of critical care, is likely
to hit India's efforts at upgrading critical care in
the country opine experts.
Here are a few hard hitting facts on critical care- There are a mere 70,000
ICU beds available (including all types and across all hospitals and small time
nursing homes) in the country which cater to five million people admitted to
ICUs every year. Fifty thousand patients die every year of which 10 per cent
die of preventable reasons or mistakes in ICU. Less than 15 per cent of ICU
patients receive dedicated intensivist care.
(Source National Accounts Statistics 2001: Mckinsey Analysis).
"This deficiency is a global phenomenon since worldwide there is dearth
of trained personnel and the number of critically ill patients are increasing,"
says Dr Shirish Prayag, past president of Indian Society of Critical Care Medicine
(ISCCM), the apex body of critical care professionals.
ICU care is 24-hour management to support failing life functions. It is very
techno-intensive, performed by a highly specialised integrated team of doctors,
nurses, paramedical staff and technicians.
According to National Accounts Statistics 2001: Mckinsey Analysis, India spends
103,000 crore on healthcare at present which will grow to be Rs 283 000 crore
by 2012. However, government and international agencies will only be able to
spend Rs 30,000 crore over the next 10 years on healthcare infrastructure. Therefore
almost 80 per cent of investment will have to come from the for-profit private
and charitable sector.
Dr Amit Varma, director, Medical Services and Business Planning at Fortis Healthcare
Limited, Noida, says, "There is a huge gap that will increase with time.
Enormous healthcare spend is needed on primary healthcare, preventive care and
specialty ICU care. 30 to 40 per cent of the entire healthcare spend will go
to specialty areas. Not too many hospitals have the financial capability to
build an ICU set-up which costs around 40-50 lakh per bed. Besides there aren't
enough trained ICU personnel in the hospitals. Since the government cannot invest
much in healthcare therefore private sector will have a major role to play in
super specialty care."
Reasons for the surging demand in critical care
Speaking about the increasing demand of critical care, Joy Chakraborty, deputy
administrator of Sri Ramachandra Medical Centre (SRMC), Chennai and member of
National Healthcare Committee, CII, said, "Due to epidemiological transition
and emergence of lifestyle diseases, population is more prone to non-infectious
chronic diseases. Change in disease pattern is leading to a condition where
patients require treatment for chronic cases and also support of critical care
units. Today, one of the major causes of mortality is road accidents. Lot of
trauma centres are in existence and many are coming to cater emergency and trauma
service. In this situation we must accept that critical care is in demand."
Agrees Dr Pankaj Harkut, resident doctor at Sir JJ Hospital,
Mumbai, "There is a surge in incidence of non-communicable diseases which
can be attributed to rapid urbanisation, change in lifestyle, genetic predisposition
etc. This has lead to an increasing demand in critical care. Secondly with open
economy we are having greater access to various equipment, gadgets and technology
required for critical care. Thirdly recent advances in field of cardiology,
neurology and neurosurgery and pulmonology have made critical care more fruitful
and rewarding in the form of decreased morbidity and mortality."
Shortage of ICU beds in hospitals
But are we equipped to meet the increasing demand in critical care?
Take for example, Bombay Hospital which has 120 ICU beds and was facing a shortage
of ICU beds, decided to add 22 ICU beds on its 8th floor to be inaugurated next
month.
Similarly SRMC which has 120 beds in different ICU's finds it difficult to admit
a genuine deserving case in its ICU, says Chakraborty. "I don't feel we
are abusing our ICU beds for our in-house patients but because our ICU has emerged
as a well known referral center in this part of the country."
"We have 120 ICU beds and have 80 to 100 per cent occupancy," informs
Dr Nikhil Kulkarni, Consultant Intensivist, SL Raheja Hospital, Mumbai.
Says Chakraborty, "Even if we go through the figures
of ICU beds available in different hospitals (claimed by various hospitals),
the data will be a misleading one. In most of the time you will find that the
basic facilities and infrastructure available in many ICUs in no way can meet
the requirement of an ICU. If we eliminate those ICU's from our consideration
then definitely we have a severe shortage of ICU beds."
Says Dr Harkut, "Definitely there is shortage of ICU beds overall besides
there is a striking contrast in rural, urban and metropolitan scenario. Specialty
wise critical care is not yet widely accepted and is mostly managed by internist
and anesthetist. One more aspect which has been overlooked is increased critical
care bed has to be matched with not only trained doctors but also trained paramedical
staff (nurses, medical attendants etc)."
Shortage of trained manpower
But here too we find a shortage of trained ICU specialists in the country. Experts
attribute the shortage of qualified ICU specialists to shortage of training
centres. For instance, no hospital in Mumbai, has a university recognised seat
in the specialty of critical care. Unlike in the field of cardiology where around
80-90 DNB and 60-70 DM seats are available, there are only 10-15 DNB fellowship
available in the field of critical care.
"In India, MCI has consistently rejected the need to set up Critical Care
as a specialty training despite the efforts of Indian Society of Critical Care
Medicine, [ISCCM]. ISCCM therefore started their own certificate training course.
Fortunately, the National board has accepted the need for such a training and
has started the fellowship. Globally, the training programme for this is being
standardised and India has been accepted as one of the few countries on this
committee for re-designing the course. India is now represented on the Executive
council of World Federation of Societies of Intensive care and is a leader in
South Asia in training and practice of Critical Care, " informs Dr Prayag.
Says Chakraborty, "We don't have many institutions to train medical professionals
in this field. We get few foreign trained specialists in our ICUs today to manage
the show. The scenario is even worst for the nursing and paramedical staff working
in the ICU. We are really lacking in our inputs to improve and manage the present
situation."
Says Dr Sumat Singhania, HoD, critical care and Dr Suresh Jain, intensivist
at Bombay Hospital, "We have 40 doctors for our 120 ICU beds. Though there
is a shortage, the situation is not as severe as in other hospitals probably
because we have one DNB seat and a local diploma seat through Critical Care
Society. But the problem worsens during examinations when doctors study for
further exams or when any doctor goes abroad. Critical Care is an upcoming field
and is going to be a special branch in time to come. In 5 to 10 years time,
good intensivists will be available," they add.
Another important aspect which needs attention is the lower remuneration paid
to these doctors as compared to other specialties. In hospitals, where doctors
are employed as consultants, they are responsible full time for the patients
but their remuneration is less than expected. “We are paid a mere Rs 150
per visit which is much lower in the 2nd class, part of the amount goes to the
hospital while some is deducted as tax. Therefore most of the doctors want to
work abroad thereby widening the gap," complains an intensivist of a leading
hospital in Mumbai.
Financial Issues
Today 15 - 20 per cent of all beds in a hospital are earmarked for ICUs. Critical
Care accounts for 20 to 30 per cent of a hospital's budget. An ICU department
is a most expensive department of a hospital in terms of high-end equipment,
antibiotics, drugs. Thus the amount put in a critical care department is huge
but payments are always a problem and therefore hospitals are very prone to
huge losses.
Depending on the specialty, a patient's treatment cost could vary from Rs 4000
to one lakh per day.
Says Chakraborty, "If you look at the commercial aspect and financial viability
of any ICU, I don't think any hospital can make huge profit out of its ICU services.
To create proper infrastructure, supply qualified manpower and specialists is
a very costly affair for any hospital. But when a patient gets admitted in an
ICU, hospital generates revenue from investigation, medicines and from procedural
charges.”
“There is no harm to make profit out of those services. Profit making motive
from ICU services will lead to a situation where patients affordability will
become an issue especially in the context of our country's population. Every
hospital cannot be managed with a philanthrophic attitude but a quick patient
turnover and adaptation of cost control mechanism can be considered as solution
for this problem," he adds.
Says Dr Varma, "Another aspect is that its difficult for a hospital to
recover money when the patient dies. There is a continuous pressure on the ICU
department. The hospital has already spend a huge amount on the patient's drugs
and on care but its efforts have been in vain as the patient has not survived.
So there is an ethical dilemma involved. Also many times the relatives can't
afford the treatment and therefore health insurance is required."
ICUs in nursing homes and public hospitals
The situation is worse in nursing homes with small setups.
These lack availability of space, facilities, adequate manpower, and high-end
equipment. Many don't even have a CT scanner and an MRI machine and shift patients
in nearby hospitals to perform any high end tests. Also public hospitals which
though have big ICUs, don't have the money to run it well and the load which
these hospitals cater to is also humongous. Thus the quality of service and
care in ICUs of public hospitals is too lacking.
But not all are complaining. Many experts feel that although the ICUs in many
nursing homes leave a lot to be desired, they share the burden of providing
healthcare thereby preventing the critical scenario from worsening. Says Dr
Prayag, "Admittedly, there could be a lack of quality but the next alternative
for a large middle class population is to go to public hospitals where ICUs
may not be of high-standard as in private hospitals, or to go to institutes
which already are facing a shortage of beds and whose charges may not be affordable
to all. The Indian hospital industry has been well served by the 'peculiar but
effective nursing homes', so let us not question their role in critical care.
There is a scope for standardisation, but these are jobs of regulatory authorities
and not of professionals."
falak@expresshealthcaremgmt.com
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