Dr Purvesh Umraniya, Consultant Intensivist, Bhailal Amin General Hospital, Vadodara highlights that the newly introduced guidelines are welcome however need to be further clarified when it comes to classifying organ failure in critical patients. A clear indication of the level of organ failure that warrants access to the Intensive Care Unit (ICU) must be defined
In the realm of critical care, the recent introduction of national guidelines has sparked discussions about their efficacy in ensuring fair access to intensive care units (ICUs) for all individuals, especially those facing economic disadvantages. According to PubMed Central, in India, there are an estimated 2.3 ICU beds available per 100,000 Indian population. India exhibits a rich tapestry of diversity, but its healthcare infrastructure contrasts in disparate ICU care availability, with significant variations in tier 1, 2, and 3 cities and remote regions, underscoring inequalities in distribution and accessibility. The growth of critical care in the urbanised states has been significantly more in the private sector where, unfortunately, the costs are very high posing a significant predicament for the underprivileged and more vulnerable segments of the population.
In dividing healthcare into public and private sectors, the redirection of most critical cases to the private sector poses a challenge for economically disadvantaged individuals. The guidelines issued recently are a strong move towards eradicating this challenge. While the base is now set, there is a great scope for improvisation and enhancements to further fill the gap and enable a seamless equitable distribution of critical care resources across the country.
Notably, the government extend support in certain medical scenarios, such as funding dialysis through initiatives for those undergoing chronic dialysis multiple times a week, its assistance primarily focuses on specific procedures, thereby aiding economically weaker sections of society. However, there is a need for specific criteria to determine the classification of cases under the new guidelines which truly cater to the unique needs of economically challenged individuals in critical care scenarios.
The newly introduced guidelines are welcome however need to be further clarified when it comes to classifying organ failure in critical patients. A clear indication of the level of organ failure that warrants access to the Intensive Care Unit (ICU) must be defined. The guidelines do provide specific criteria for certain aspects, such as oxygen desaturation, low blood pressure, or hypotension, which are classified. Yet, the guidelines fall short of specifying particular numerical values, like a specific heartbeat or a defined oxygen level, that would necessitate ICU admission.
In essence, while healthcare personnel are provided with a comprehensive understanding, there’s a notable absence of precise objective numbers. This leaves the decision-making process reliant on factors like altered consciousness, impact on the brain, hemodynamic instability, and signs of shock, which need on-the-spot evaluation by the attending healthcare professional in the bedside or emergency setting. The absence of objective numbers for certain criteria, coupled with a recognition of advance directives or patient wishes not to be admitted to the ICU during emergencies, adds complexity to decision-making in critical situations.
The government has taken a commendable step by recognising the importance of honouring the wishes of individuals with advance directives or a clear preference against admission to the hospital or ICU during emergencies. This thoughtful approach extends to the patient’s family or next of kin, emphasising that if they express a desire for the patient not to be admitted to the ICU, that request should be respected. This inclusion in the guidelines is a noteworthy development, potentially aiding healthcare personnel in decision-making. While this inclusion is a positive step, offering clarity on not admitting patients with stated preferences to the ICU, there remains a need for further guidance in situations where patients are critically ill and incapable of making decisions in real-time.
The national guidelines for critical care offer a plethora of priority-based benefits to the deserved ones. While they provide a broader understanding for healthcare personnel, we positively look forward to further strengthening these guidelines for a more comprehensive approach to guarantee equitable access to the ICU, creating an inclusive advantage for all individuals in need of critical care.