India is a rapidly developing lower-middle income country.(11 The World Bank. Data. Countries and lending groups. Available from
http://data.worldbank.org/about/country-and-lending-groups#Lower_middle_income.
Accessed February 1, 2015
http://data.worldbank.org/about/country-...
) There has been a tremendous increase
in the knowledge, technology and skills that are required to treat critically ill
patients in India over the last twenty years. Intensive care is expensive care, and the
provision of critical care services can be challenging in the existing socio-economic
environment.
COSTS OF CARE
Health care facilities in India are either privately run institutions or publicly
funded. Most intensive care unit (ICU) beds in India are in private hospitals. The
relatively few ICU beds in public hospitals, which offer free treatment, constitute
approximately 10% of the critical care facilities in India. Health insurance and
social security are almost nonexistent, and 57.6% of the total health care bill is
paid out of pocket by the patient or their family.(22 World Health Organization. Global Health Observatory Data Repository
(2014) Health expenditure ratios: data by country. Available from
http://apps.who.int/gho/data/node.main.75. Accessed February 1, 2015
http://apps.who.int/gho/data/node.main.7...
) The daily cost of ICU care may be approximately 100
times the per capita income.(33 Kulkarni AP, Divatia JV. A prospective audit of costs of intensive care
in cancer patients in India. Indian J Crit Care Med.
2013;17(5):292-7.) Therefore, a single episode of ICU admission can impoverish
families. However, innovative funding schemes by various state governments and
contributions from social organizations have enabled increasing numbers of patients
to access advanced healthcare facilities. There is a definite role for intensive care
because of the relatively young population and the significant burden of severe
tropical infectious diseases, trauma, poisonings and envenomations and the rising
incidence of non-communicable diseases, such as diabetes, coronary artery disease and
cancer. Indeed, intensive care in India may be no more expensive than the costs of
treating non-Hodgkin’s lymphoma.(33 Kulkarni AP, Divatia JV. A prospective audit of costs of intensive care
in cancer patients in India. Indian J Crit Care Med.
2013;17(5):292-7.) It is essential to increase the number of ICU beds and
upgrade the facilities and staffing in public hospitals.(44 Divatia JV, Iyer S. Ten major priorities for intensive care in India.
Intensive Care Med. 2015 Jan 9. [Epub ahead of print].) Investment in intensive care,
including that in equipment, organization, staffing and education, may increase the
initial costs, but these efforts will prove to be cost- effective in the longer
term.
INTENSIVE CARE MANPOWER
The Indian Society of Critical Care Medicine (ISCCM) was formed on October 9, 1993,
and it has been the catalyst for the systematic growth of critical care in
India.(55 Divatia JV, Jog S. Intensive care research and publication in India: quo
vadis? Intensive Care Med. 2014;40(3):445-7.) At the
society’s inception, critical care medicine was not recognized as a specialty by the
Medical Council of India (MCI), which was the apex body for accreditation of
postgraduate medical education. The ISCCM introduced a 1-year Indian Diploma in
Critical Care (IDCC) in 1996 to overcome this lacuna, followed by a two-year Indian
Fellowship in Critical Care (IFCC) in 2007. Over 130 ICUs have been accredited, and
more than 60 intensivists graduate annually.(66 Indian Society of Critical Care Medicine - ISCCM. ISCCM courses.
Available from http://isccm.org/courses.aspx. Accessed February 1,
2015
http://isccm.org/courses.aspx...
) It was only in 2012 that the MCI recognized
critical care as an independent specialty, which enabled 3-year training programs
after a postgraduate base specialization that led to a university degree in critical
care.
Similar problems exist in the development of manpower in critical elements of the Critical Care Medicine team, including critical care nurses, technicians, respiratory therapists, nutritionists, physiotherapists, and clinical pharmacists. Training programs and courses by professional societies, hospitals and medical colleges are required to develop the manpower to staff and run modern ICUs.
The ISCCM has guidelines and standards for ICU design, structure, function and
quality of care.(77 Guidelines Committee ISCCM. Intensive Care Unit Planning and Designing
in India: Guidelines 2010. Available from http://isccm.org/images/Section1.pdf.
Accessed February 1, 2015
http://isccm.org/images/Section1.pdf...
,88 Indian Society of Critical Care Medicine 2009. Quality indicators for
ICU. Available from http://isccm.org/images/Section8.pdf. Accessed February 1,
2015
http://isccm.org/images/Section8.pdf...
) However, accreditation by the
National Accreditation Board for Hospitals and Healthcare Providers (NABH) is
voluntary, and a vast majority of hospitals and ICUs are not accredited or graded.
The ISCCM has also produced guidelines on the roles and responsibilities of the
consultant intensivist in hospitals.(99 Indian Society of Critical Care Medicine Committee on Defining the
Functions, Roles and Responsibilities of a Consultant intensivist. Critical Care
Delivery in Intensive Care Units in India: Defining the Functions, Roles and
Responsibilities of a Consultant intensivist. Available from
http://isccm.org/images/ISCCM%20Intensivist%20guidelines.pdf. Accessed February 1,
2015
http://isccm.org/images/ISCCM%20Intensiv...
) Many centers have trained intensivists manning their ICUs,
and intensivists now command greater respect and salaries than in the past.
END-OF-LIFE CARE
Euthanasia and physician-assisted suicide are not legal, but the courts have not explored concepts such as autonomy and death with dignity. The ethical and legal status of withholding or withdrawing life-sustaining treatments (WH/WD) is ambiguous. The Supreme Court of India clarified that WH/WD in a terminally ill patient is permissible in a recent judgment that pertained to a patient in a persistent vegetative state, provided that prior approval is obtained from the concerned High Court. However, this procedure is impractical for the ICU setting.
Barriers to end-of-life care in India include fear of legal ramifications, unawareness of ethical issues, the culture of “fighting till the end”, lack of orientation to palliative care, and the pressure to admit futile cases of self-paying patients.(1010 Mani RK. End-of-life care in India. Intensive Care Med. 2006;32(7):1066-8.) Nevertheless, WH/WD occurs in 19-50% of deaths in Indian ICUs.(1111 Kapadia F, Singh M, Divatia J, Vaidyanathan P, Udwadia FE, Raisinghaney SJ, et al. Limitation and withdrawal of intensive therapy at end of life: practices in intensive care units in Mumbai, India. Crit Care Med. 2005;33(6):1272-5.) The withholding of life support is more common, and withdrawal of life support occurs in only 8% of cases. Left against medical advice (LAMA) appears to be a common practice, in which the patient is transferred out of the ICU terminally for financial or other reasons. LAMA deprives the patient of palliative care, analgesia and comfort care at the end of life, and it is strongly discouraged in the position statement of the ISCCM and Indian Association of Palliative Care.(1212 Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med. 2014;18(9):615-35.)
NOSOCOMIAL INFECTIONS AND ANTIMICROBIAL RESISTANCE
One study(1313 Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al.
Device-associated nosocomial infection rates in intensive care units of seven Indian
cities. Findings of the International Nosocomial Infection Control Consortium
(INICC). J Hosp Infect. 2007;67(2):168-74.) conducted
in 12 ICUs in seven Indian cities reported rates of healthcare-associated infections
that were much higher than the United States NNIS benchmarks. There are several
reports of an alarming proportion of infections with resistant
Pseudomonas, ESBL-producing Enterobacteriaecae
and Acinetobacter. One worrying feature is the increasing problem of
carbapenem resistance.(1414 Deshpande P, Rodrigues C, Shetty A, Kapadia F, Hedge A, Soman R. New
Delhi Metallo-beta lactamase (NDM-1) in Enterobacteriaceae: treatment options with
carbapenems compromised. J Assoc Physicians India. 2010;58:147-9.) It is essential to have a nationwide
program(1515 Government of India. Directorate General of Health Services. Ministry of
Health & Family Welfare. National policy for containment of antimicrobial
resistance in India (2011). Available from http://nicd.nic.in/ab_policy.pdf. Accessed
February 1, 2015.
http://nicd.nic.in/ab_policy.pdf...
) to
monitor antibiotic resistance and strategies for education and antibiotic
stewardship. The use of overall hospital data or Western literature to guide
antimicrobial therapy in an ICU may be inappropriate. Professional and government
organizations need to work together to fight the threat of antibiotic resistance.
RESEARCH
It is vital that research be performed in areas of critical care medicine that are relevant to India. We first require adequate information and baseline data about our ICUs, practices and patients. The Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) study of the ISCCM acquired data of 124 ICUs and over 4000 patients. The results should be available soon.
This article focused on the progress and challenges in critical care medicine in India. Challenges remain in infrastructure, human resource development and critical care delivery across the country, and we continue to strive for solutions to make our ICUs safer and to provide better care and outcomes for our patients.
-
Responsible editor: Jorge Ibrain Figueira Salluh
REFERÊNCIAS
-
1The World Bank. Data. Countries and lending groups. Available from http://data.worldbank.org/about/country-and-lending-groups#Lower_middle_income. Accessed February 1, 2015
» http://data.worldbank.org/about/country-and-lending-groups#Lower_middle_income -
2World Health Organization. Global Health Observatory Data Repository (2014) Health expenditure ratios: data by country. Available from http://apps.who.int/gho/data/node.main.75. Accessed February 1, 2015
» http://apps.who.int/gho/data/node.main.75 -
3Kulkarni AP, Divatia JV. A prospective audit of costs of intensive care in cancer patients in India. Indian J Crit Care Med. 2013;17(5):292-7.
-
4Divatia JV, Iyer S. Ten major priorities for intensive care in India. Intensive Care Med. 2015 Jan 9. [Epub ahead of print].
-
5Divatia JV, Jog S. Intensive care research and publication in India: quo vadis? Intensive Care Med. 2014;40(3):445-7.
-
6Indian Society of Critical Care Medicine - ISCCM. ISCCM courses. Available from http://isccm.org/courses.aspx. Accessed February 1, 2015
» http://isccm.org/courses.aspx -
7Guidelines Committee ISCCM. Intensive Care Unit Planning and Designing in India: Guidelines 2010. Available from http://isccm.org/images/Section1.pdf. Accessed February 1, 2015
» http://isccm.org/images/Section1.pdf -
8Indian Society of Critical Care Medicine 2009. Quality indicators for ICU. Available from http://isccm.org/images/Section8.pdf. Accessed February 1, 2015
» http://isccm.org/images/Section8.pdf -
9Indian Society of Critical Care Medicine Committee on Defining the Functions, Roles and Responsibilities of a Consultant intensivist. Critical Care Delivery in Intensive Care Units in India: Defining the Functions, Roles and Responsibilities of a Consultant intensivist. Available from http://isccm.org/images/ISCCM%20Intensivist%20guidelines.pdf. Accessed February 1, 2015
» http://isccm.org/images/ISCCM%20Intensivist%20guidelines.pdf -
10Mani RK. End-of-life care in India. Intensive Care Med. 2006;32(7):1066-8.
-
11Kapadia F, Singh M, Divatia J, Vaidyanathan P, Udwadia FE, Raisinghaney SJ, et al. Limitation and withdrawal of intensive therapy at end of life: practices in intensive care units in Mumbai, India. Crit Care Med. 2005;33(6):1272-5.
-
12Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med. 2014;18(9):615-35.
-
13Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;67(2):168-74.
-
14Deshpande P, Rodrigues C, Shetty A, Kapadia F, Hedge A, Soman R. New Delhi Metallo-beta lactamase (NDM-1) in Enterobacteriaceae: treatment options with carbapenems compromised. J Assoc Physicians India. 2010;58:147-9.
-
15Government of India. Directorate General of Health Services. Ministry of Health & Family Welfare. National policy for containment of antimicrobial resistance in India (2011). Available from http://nicd.nic.in/ab_policy.pdf. Accessed February 1, 2015.
» http://nicd.nic.in/ab_policy.pdf
Publication Dates
-
Publication in this collection
Mar 2015
History
-
Received
03 Feb 2015 -
Accepted
11 Mar 2015