Recently, Fortis Hospital, Kalyan announced plans to transform its critical care unit into a ‘Centre of Excellence’ with a focus on evidence-based protocols, training, and capacity building of critical care specialists. Dr Rahul Pandit, Director-Critical Care, Fortis Hospitals Mumbai and Member of Maharashtra’s COVID-19 Task Force shares more details about the endeavour, the gaps and challenges in India’s existing critical care system, lessons learnt from the COVID-19 pandemic, need stronger collaborations between private and public healthcare sectors and more, in an interview with Lakshmipriya Nair
The COVID-19 pandemic strained our critical care systems and infrastructure. What are the biggest gaps and challenges in our existing systems?
The pandemic inflicted a huge strain on the country’s critical care infrastructure. Critical care services throughout the nation were challenged and stretched beyond limits. We were three times short of trained doctors to look after critical patients and those in need of intensive management. The number of trained nurses and paramedical staff to support this pandemic were even shorter than doctors. Also, in the rural parts of the country, there are hardly any critical care specialists to contribute to COVID-19 care.
In India, training for healthcare professionals in critical care management picked pace in the past ten to 15 years, therefore it has not percolated to rural India. There is huge scope for improvement in the training of critical care specialists. A comprehensive process needs to be established to train doctors and other medical professionals to cater to the critically ill population.
How do we need to transform our healthcare system to be more future-ready in terms of critical care, especially for contagious/infectious diseases?
During the pandemic, the biggest gap was seen in trained manpower. So, firstly we need to establish critical care as a super-speciality discipline in medical colleges and teaching institutes. Currently, we have a handful of colleges that provide this super-speciality training in India. We need to have super-speciality training across all the medical colleges in India. Secondly, the attitude towards critical care as an independent speciality needs to change. The role and importance of critical care and an intensivist has changed quite significantly due to the pandemic. Thirdly, in metro cities, there should be independent or separate hospitals and units catering to patients suffering from infectious diseases. As far as India is concerned, we need to upgrade and revamp infectious disease services to address the many gaps in our system.
If we look at the last 20 years, the world has gone through several infectious disease episodes. In 2003- 2004 the SARS epidemic in Hong Kong and China was followed by H1N1, Avian influenza, Ebola, and now the COVID-19 pandemic. We also experience tuberculosis endemic in India. Therefore, in India, the need of the hour is to build robust critical care and infectious disease centres which can cater to a large number of patients.
What role does Fortis envisage for itself in this transformation? How are these goals inculcated in the new Centre of Excellence at Fortis Kalyan?
Fortis Hospitals have always been at the forefront as far as critical care services are concerned. Fortis Mulund unit has been recognised for training by the Indian Society of Critical Care Medicine for both diploma and fellowship courses, Diplomat of National Board, (DNB) for DNB Critical Care medicine, and by the College of Intensive Care Medicine of Australia for training. They found our standards and treatment protocols at par with the Australian hospitals and teaching institutes.
What we intend to do in Kalyan is to not only ramp up our expertise for critical care but also to inculcate a culture of education and introduce new training programmes. Also, we would like to enhance our protocols for caregiving and make it standardised across all units. We would like to bring across a quantum change in which patients who come to any centre can find the same kind of quality care standards. We would also like to bring about a sense of responsibility and empowerment among our nursing staff to ensure high-quality care at all levels.
Some of the infection control policies and as well as key performance indicators (KPIs) will be enhanced – bloodstream infections, surgical site infections, reincubation rates etc., will be looked at; alongside, protocols will be put in place to achieve better outcomes.
What are the short-term and long-term steps needed to build our capabilities in terms of our workforce and their skills for critical care services?
Workforce capability training is never a short-term goal, it is always a long-term goal. To build-up for the future, it takes up one to two years before we can have an ongoing teaching programme. A long-term plan not only looks at training medical professionals but also looks at establishing career growth for those enrolling for the programme. The beauty of this programme lies in the fact that it is designed in such a way that in future, our specialist-to-patient ratio will be 1:15 in the ICU unit, which is the internationally accepted ratio for optimal patient outcomes.
What are the biggest lessons for critical care management (protocols, policies) from the pandemic?
The biggest lessons for critical care management learnt during the pandemic is that India needs to strengthen its critical care workforce and put all the patient doubts and anxieties to rest. There were these pressing concerns and various rumours that patients on life support for COVID-19 care weren’t doing well and that there is a delay in treatment. It took us a good four to five months to convince people and gain their trust in the quality of care provided and the outcomes were good. It is not the ventilator which treats the patient, it is the care that is provided that helps the patient recover faster.
There is a lot of ignorance among patients and doctors alike about critical care management. But the efforts taken to upgrade and train professionals in critical care made a big difference in management and outcomes.
How should hospitals of the future adopt and implement digital solutions within their OTs and ICUs to transform critical care?
One of the big opportunities in critical care is the use of digital platforms. Electronic ICUs are no more things of the past. We have a lot of solutions where physicians can remotely monitor patients. They act as a second safety net and can support doctors with critical health information. They also help in enhancing clinical outcomes through connect health services. For instance, if you have on-ground medical personnel trained to do the procedure, the Intensive Care Specialist can guide reasonable therapy even from a far off place. This improves clinical and patient outcomes. Timely referral to a special care unit is extremely important as well.
Stronger collaborations between private and public healthcare stakeholders will also be crucial to strengthening the country’s critical care system. In your opinion, how can such collaborations be facilitated?
Currently, modern intensive care practices are well established at some of the private hospitals in the country. Whereas many public hospitals, barring a few, lack basic critical care services. To improve this infrastructure, public-private partnerships (PPP) are the right way. The partnership basically should include manpower and resources enhancement. This can be done by way of involving private sector critical care specialists to work with the government as part of public programmes or on an honorary basis so that patients at government hospitals also get specialised care and these doctors can be a part of the upskilling and training programmes. It will take five to seven years for us to double the number of intensivists if we start work from today. If we don’t work from today, then we might not be able to rebuild or save our crippling healthcare system.