From Good to Better: Critical Care

Over the years, Indian critical care has undergone a significant transition with the emergence and expansion of private hospitals, explains Sonal Vij

Like most developing countries, critical care medicine as a speciality has developed quite slowly and only in the recent past in India. "Over the last five years Indian critical care practices have evolved significantly. Critical care initially began as a minor service in large tertiary care hospitals, which has now evolved into a major service basket in secondary and tertiary level hospitals across the country," says, Pradip Kanakia, National Head of Markets and a member of KPMG India Leadership Team.

He explains that previously, critical care was localised to isolated areas of excellent patient care, with the emphasis being on patient care and service rather than on development of a specialty training or research. The most important achievement of these units was not only to lower the mortality of tetanus but also to open the eyes of society to the need of critical care services.

But today, there is availability of hospital ICUs with the right infrastructure, physician support, trained nursing and inter-disciplinary backup support. Also, experts believe that Indian critical care industry has still been 'catching up' with concepts practiced in the rest of the world. Explains Dr Lloyd Nazareth, COO, Wockhardt Hospitals Group, "Earlier we had intensive care units where the staff in the ICU merely played the role of supporting mechanical devices and ventilators and all decisions were made by the admitting doctors. But that is not the case today." In corporate hospitals and in majority of the teaching hospitals, there is availability of well-equipped, sophisticated critical care units and its variants like Surgical Intensive Care Unit (SICU), Paediatric Intensive Care Unit (PICU), Neonatal Intensive Care Units (NICU).

As for the technology, the market has evolved towards higher automation and information integration at the point of care. "Instead of having to see many reports, today clinicians want to see all information integrated into one point at the patient monitors on the bedside under a single unified patient identification," says Jitesh Mathur, General Manager, PMCC, Philips Healthcare. He also explains that the ICU charts which were maintained earlier manually in handwriting are moving towards electronic charting systems which automatically record patient vital signs and progress, therapy and drugs given— creating electronic records and removing the chances of human error.

Corporates Targeting Critical Care

"To tap or not to tap critical care segment is not a choice. It is a necessity for any serious player in the healthcare industry," says Murli Nair, Partner, Business Advisory Services Ernst & Young. He explains that this is primarily driven by the shift in opportunity landscape, shift in disease profile towards non-communicable disease which requires a higher degree of critical care support and untapped opportunities/ unaddressed markets like trauma care. Therefore, the healthcare companies have plans to set up trauma care facilities along the golden quadrilateral or along major highways. A clear example of this is Rockland Hospital in Delhi which is setting up a 250-bed hospital in Manesar with trauma and critical care as a specialty. The number of critical care beds will increase from the present 17 to 27 beds in the next one year. The upcoming 250 bed multi-specialty hospital in Manesar (NCR) will have 42 critical care beds. This reveals the clear focus of the hospitals towards critical care.

Pushpanjali Crosslay hospital in Vaishali (NCR), situated close to NH-24, also has trauma and critical care as it's' specialty.

Along with the need, there, is a huge financial viability in tapping this market. According to a FICCI healthcare report, the average ICU occupancy levels stand at 84 per cent for hospitals between four to seven years of maturity and 93.5 per cent for hospitals with more than eight years maturity. Undoubtedly, critical care is also a profitable venture for a hospital. The average cost per day for the patient may vary from 15-000 to 50,000 or even more depending on the criticality of the patient. The inability of the public sector to be able to tap this market is also a reason for the private players to be encouraged to tap this market. " Due to heavy investment requirements to the tune of around Rs 40-50 lakh per bed, public investment has not ventured sufficiently in the area of critical care. This gap is constantly being filled by the private healthcare players," explains Kanakia. Also, if a patient's life is saved, he provides publicity of the hospital by word of mouth.

At Max Hospital Saket and Max Devki Devi Heart Institute, additional critical beds are being added to meet the demand of shortage of beds. "We are unable to treat patients. We are running short of beds. There is a waiting list. Therefore, 30-40 beds will be added to the present 140 beds," says Dr Omender Singh, Head, Department of Critical care, Max Hospitals.

Dr Mayur Patel, Physician and Intensivist, Jaslok Hospital, Mumbai reveals that the hospital would want to expand in terms of the number of beds but is not able to do so, due to space constraints. The increase in the number of critical care beds can definitely be judged by the fact that the hospital which initially had 10-12 critical care beds, now has 60 critical care beds today.

At Manipal Hospitals too, the number of critical care beds will increase but the officials have not revealed the numbers.

At Apollo Hospitals, Chennai, there are presently 75 critical care beds. Another 25 beds will be added in the next one year. "Wockhardt, Bangalore will increase the existing 150 critical care beds to 250 in the next three years," informs Nazareth.

Trends

As for the present trend, experts see a clear trend of doctors entering the critical care industry. "The market is witnessing more and more full-time specialists in this domain," reveals Somnath Chatterjee, Consultant - Head of Department, Critical Care Medicine, Manipal Hospital, Bangalore. Previously, critical care was managed by a mix of doctors who were physicians, anaesthetists or pulmunologists who had gradually gained experience by working in ICUs. "The only trained professionals were those who received training from abroad. There is a gradual shift in this aspect with the emergence of certificate courses and DNB programmes," says Nair. Today, there is a shift towards specialised training. This may lead to closed/ semi-closed critical care units (closed units are those where the clinical management is done completely by the intensivists and not by the consultant doctors).

Explaining the changes in the Indian critical care industry, Nair elaborates that while the Government sector is purported to allocate 10 per cent of the budget, the private sector is allocating relatively higher budgets —20-30 per cent. "This is being primarily driven by the focus on super-specialties like cardiology, neurosurgery etc. This is also accompanied by a change in bed mix— earlier where ICU beds accounted for 10-15 per cent of the total beds, this is increasing to 15-20 per cent of the total beds in the new set-ups," he explains. However, this change can be said to be largely restricted to tier I cities which have not only been the centres for super-specialty tertiary care, but also have been the focus area for major healthcare players.

"Over the last few years, there has been a tremendous increase in the knowledge, technology and skills in treating critically-ill patients. This has lead to the development of specialised intensive care units," says Monica Sood, Head, Healthcare Practices, Feedback Ventures. This is a trend that will continue to grow in the future. "If a patient with stroke will come, he will be admitted into a neurological ICU and so on. There will also be more cardiac ICUs," says Patel. He admits that more and more data will be available online allowing services like drug to drug interaction.

Another recent trend (change) that has been observed is of outsourcing critical care services to professional intensivist for patient management. "Moving forward as acceptability improves, more hospitals could experiment with this model to minimise the time their consultants spend on high dependency patients and allow them to focus on more specialised procedures of their own specialty," explains Nair.

A trend observed towards increasing focus on quality and safety of medical care because of the high cost of healthcare and potential for harm. Many doctors believe that hospital acquired infections are also increasing. "Quality improvement initiatives in the ICU to decrease nosocomial infections and maintenance of normoglycemia (normal glucose content of the blood) have been shown to improve outcomes as well as decrease costs," says Kanakia. More and more hospitals are paying attention to decrease hospital acquired infections. Dr Nazareth explains that in the past few years, the safety standards have definitely improved across many of the ICUs. He adds that one sees a definite move towards non-invasive ventilation. This benefits the patient in reducing length of stay, complications and infection rates.

In absence of fixed guidelines, the hospitals are developing their own guidelines. "Over the last five years there is a serious move to get protocol and guideline driven. Many ICUs are tracking outcomes, many have put in place standard protocol-driven infection control practices which have had major impacts on reducing nosocomial infections rates," says Dr Nazareth.

Standalone and Hub-and-Spoke

Apart from critical care facilities provided under the hospital umbrella, there has been a trend of standalone facilities providing critical and trauma care. AIIMS in Delhi is an example which today has a separate trauma and critical care centre. Also more and more hospitals are using hub and spoke model in critical care where the main hospital provides the critical care and the network hospital is utilised for patient recovery. "Wockhardt Hospitals intends to expand its reach in the high-end intensive care segment by setting up standalone regional ICU hospitals," says Dr Nazareth.

In the future, there will be a time when there will be a substantial need for more quality ICU beds per city. "Today in a single city like Bangalore my hospital network has already created a network of 150 critical care beds across five locations, all interconnected with a good ambulance network," says Nazareth. This trend will grow.

However, point to be noted as for the growth, is that right now, the trend of growth is restricted to tier I cities. However, this may change in future as many of the healthcare companies are having plans to enter the tier II cities in a big way.

So what do we expect from this industry 10 years from now? As of today, apart from accessibility and affordability of healthcare services, quality is increasingly becoming a focus area. "One could expect some more regulations/ norms guiding the setting up of critical care facilities in both Government and private hospitals. Quality accreditation and certification could become mandatory," says Nair. He elaborates that with increasing shift in disease profile towards non-communicable / life-style diseases which demand higher support from critical care units, the need for higher degree of specialisation in critical care may increase. In turn, this would lead to formalised training not only for intensivists but also for para-medical staff becoming a more regularised feature/ norm. (This is already being witnessed) and clear emergence of semi-closed and closed critical care units. "We might also see the emergence of long-term acute care units in the standalone formats, near the existing hospitals where further expansion is not feasible," he explains.

Challenges in setting up a ICU

The biggest challenge in setting up an ICU faced by the industry is the shortage of trained manpower. Most experts believe that at present everything is available, the funding, machinery, technology but we are in acute shortage of manpower. "Today the main challenge is in finding the adequate trained manpower like doctors, intensivists, technicians and high-end nurses," says Sood. While the concept of the intensive care unit has gained widespread acceptance amongst medical professionals, hospital administrators and the general public, recognition of the need and role for doctors specialising in intensive care medicine, has lagged behind. "One of the reasons may be that intensive care medicine is a relatively new speciality. Social, political and economic factors also undoubtedly play a role in preventing wholehearted acceptance of a consultant intensivist in the hospital," says Kanakia.

With a variety of equipment available today, Mathur believes that it is an additional challenge to select the right equipment which must have required FDA or equivalent regulatory approvals.

Since critical care and trauma services in India are at initial stages of development; industrialised cities, rural towns and villages co-exist, with variety of healthcare facilities and almost complete lack of organised trauma care. "There is gross disparity between trauma services available in various parts of the country," says Kanakia. It is very difficult to provide services like trauma care in rural India due to a variety of reasons such as varied topography, financial constraints and lack of appropriate health infrastructure. There is no national lead agency to coordinate various components of a trauma system. Therefore, setting up an ICU unit is a challenge.

Tier II and Tier III Challenges

The two daunting challenges in tier II Vs tier I is manpower resources and financial viability. A researcher remarks that 25-35 per cent of the capital is invested in critical care in a hospital, but the revenue realisation is much lesser in a tier II compared to tier I. Nazareth explains that in tier II cities, apart from the severe shortage of qualified and trained intensivists and nurses, the issue of affordability poses a challenge for the hospitals. "Unfortunately in the absence of adequate payor mechanisms, quality critical care is not affordable to many in tier II cities," he adds.

Dr Ravi Khanna, New Born Child & Critical Care Centre (NBCC), Bareilly (UP) points that they train 10+2 students into nursing and absorb them. Moreover, they have to pay the salaries demanded by the doctors and comply with their tantrums in order to sustain them and keep the work going.

Also, there is lack of education in smaller cities, therefore it is difficult to make them understand so as to why is critical care required by the patient. Here, soft skills play a vital role. A doctor practicing in tier II and tier III cities has to be more patient and more versed with soft skills compared to Tier I.

In case of a death of the patient, many times a doctor is harassed by the patient relatives. A doctor confesses, "My clinic has been stoned many times, I have dealt with life and death situations," adds Khanna. The increasing influence of politics sometimes becomes a problem. "Already its difficult for us to make the ends meet and the relatives of politicians come to us and ask for discounts!" he adds.

Tier II and tier III doctors also believe that it is difficult for them to get maintenance of machinery. A doctor elaborates that in case of a metropolitan city, one can go to the company showroom and test the machines and choose from a good variety. However, in smaller cities, the doctors believe that they have to rely on the companies which approach them. As far as the maintenance goes, the companies take much longer time to revert to them because of the proximity of the distance.

Since, the power supply is a problem in smaller cities; the vendors believe that the equipment has to be designed accordingly. "The importance of a battery backup time of up to four hours has a major advantage in many cities in India where supply of stable power supply is limited," says Mathur.

What most fear is that since there are no norms for ICU in place, many small nursing homes use second-hand machinery to save on cost and don't have safety standards in place. This poses a threat to the life of a patient.

The road Ahead

Critical care services still have a long road to walk in India, in terms of providing patients' multi-discipline support or pre-hospital care to accident victims.

The future appears to be both daunting and challenging. "It is estimated that from its present position of the ninth leading cause of deaths in India, trauma will move up to third position by 2020. It is also estimated that in the developing countries over six million will die and 60 million will be injured, or disabled, in the next 10 years," says Kanakia. India will have a large share in this, with an estimated economic loss of around two per cent of GDP. He explains that to meet this challenge several efforts are required— resource creation, education, legislation, upgrading pre-hospital and hospital based care, public awareness and a change in the attitude of the policy-makers. The public health institutions will also benefit from adopting WHO Essential Trauma Care guidelines for trauma care, which is aimed at low cost improvements to the trauma care. There are already some ongoing efforts in that direction.

Although the overall picture in trauma care is not as dismal as it used to be three decades ago, 'trauma care for all' continues to remain a distant dream in India. Despite significant overall progress in many other fields, trauma systems in India continue to remain at a formative stage for various reasons.

Despite the growth, lack of manpower resources, absence of guidelines definitely pose a threat to this industry, "Unfortunately today in the absence of any guidelines or minimum standards required for an ICU, one has a large number of ICUs which simply do not meet bare minimum standards required," avers Nazareth.

"A concerted effort from all the parties involved, as well as the society, is the need of the hour," he concludes Kanakia. Elaborates Dr Shirish Prayag, Chief Intensivist, Shree Medical Foundation, "Development of guidelines for the working of ICUs has been another important issue that the ISCCM has taken up. The guidelines are currently being formulated. For a country that has it own set of problems, such independent guidelines will be very vital."

sonal.vij@expressindia.com