Management

Evolution of Critical Care in India

The patterns of medical problems seen in Indian ICUs are dissimilar to those seen elsewhere

"Future challenges include the development of guidelines, the consolidation of training activities and research on the outcome of critical tropical problems which are peculiar to our country" - Dr Rajesh Chawla Senior Consultant Respiratory & Critical Care Medicine Indraprastha Apollo Hospitals, New Delhi

Critical care practices in India have evolved significantly over the past two decades. Critical care medicine is a brand of medicine concerned with the provision of life support for critically ill patients. Critical care initially began as a service in major hospitals, but with the formation of the Indian Society of Critical CareMedicine, the development of this speciality has been very rapid.

Brief History

Indian Society of Critical Care Medicine (ISCCM), an association of intensivists with over 4,000 members and 16 city branches has played a great role in the growth of critical care in India. The coronary care units were developed in the early to mid-1970s.Around the same time Dr Farokh E Udwadia, developed the first respiratory care unit in two hospitals of Mumbai- a community hospital and a private one. The most major achievement of these units was not only to bring down the mortality of tetanus, but also to open the eyes of society to the need for critical care services. However, organised critical care medicine in India as a speciality has developed very slowly and only recently.

Levels of Care

There are three types of hospitals in India that are delivering patient care in India. Community hospitals are mostly run by the government and essentially result in no cost to the patients. Critical care is a branch that involves a lot of technology and therefore is dependent on finances. Hence, there have been limitations to the growth of this branch in community hospitals. There are currently about 200 medical colleges with hospitals attached to them in India. Additionally, there are more than 1,000 district hospitals. It is estimated that only a small proportion (<10 per cent) of all these hospitals, however, will boast properly equipped or staffed Intensive Care Units (ICUs). These hospitals thus contribute only a small proportion of the available ICU facilities.

Private tertiary care hospitals like Indraprastha Apollo Hospitals, Max Hospitals and Fortis hospitals and many others are managed by societies, trusts or companies. Patients are levied a charge for these services. There are also a small percentage of beds that are provided for free. As per the current estimation, 85 per cent of patients are self-paying. ICUs in private tertiary care hospitals are usually very well equipped and thus form the most major contributor to the critical care facilities in the country, albeit at a higher cost to the patient which can vary from 20,000 to 50,000 per day which is really not possible for most of Indians. Most of the equipment used are imported and very expensive. There is great need to manufacture these equipment in the country to make them cheaper. The drugs and antibiotics used are very costly. Many of the patients sell their assets to pay the hefty bills.

Nursing Homes: Worth a Mention

An interesting segment of healthcare facilities in India consists of small hospitals or nursing homes. Modestly equipped and managed mostly by medical professionals themselves, these are realities representing the vast middle and lower classes, and they contribute about 40 per cent of available beds for the country. The patients also usually pay for the services here. The need and the viability of facilities for critical care are being acknowledged by this segment, and currently the facilities are on the upswing.

Indian ICUs: Unique Challenges

The patterns of medical problems seen in Indian ICUs are dissimilar to those seen elsewhere. These also change with the categories of the hospital. A number of tropical infections such as malaria, leptospirosis, tuberculosis, salmonellosis, etc. form a significant proportion of the patients. Poly-trauma also a rank high in the occupancy charts. Even today, the mortality from severe sepsis in our country is very high.

Manpower development of the specialists has been a major issue. Most of the current directors in the past have been trained abroad.

Train the Trainers

The certificate course in critical care, the first organised training activity in critical care medicine, was started few years ago by the ISCCM and has been evolving well. A number of hospitals have developed training modules, and more students are coming out of this training programme regularly. The ISCCM has also been very active in interacting with various medical councils in India. With this, the first steps for training in critical care on a national level curriculum are now being taken. The training of nurses, technicians, and therapists has begun in some isolated foci but has not evolved into a meaningful training activity. Nurses form the real providers of critical care. The outcome of critically ill patient is dependent on team work involving administrator, doctor, nurses and technicians.

Critical Juncture

Critical care in India is at the crossroads of development. The beginning looks good but a long part still has to be travelled. Highly dedicated efforts can only lead to humane, scientific meaningful service for the multitude of their critically ill patients. Future challenges include the development of guidelines, the consolidation of training activities and research on the outcome of critical tropical problems which are peculiar to our country.

drchawla@hotmail.com