Covid-19: Making critical care relevant and humane

In the times of ongoing pandemic, one of the solutions to prevent deaths that has attracted the largest attention is provision of critical care. In fact, the earliest modelling exercises carried out by scientists at Imperial College were largely aimed to predict the numbers of people who would require intensive care at the peak of the epidemic and how can that period be prolonged to prevent overwhelming of the system.

Since availability of mechanical ventilation is an important component of critical care, the discussions since then have revolved around availability of ventilators. Not only in public discourse but even the policy response in India has been to procure more ventilators to prevent deaths due to Covid-19. For example, the largest expense from PM-Cares fund has been towards procurement of ventilators.

However, the ventilator care has not lived up to its initial promise. In New York City, nine out of 10 persons provided ventilator care died. Since then, there have been revised technical guidelines and clinical practice that are much more cautious on early use of ventilators.

Critical care services are meant as clinical services that meet the needs of patients facing an immediate life-threatening health condition—specifically, that in which vital system organs are at risk of failing.

Critical care is a continuum starting from triaging, emergency room care, transport to intensive care unit, and then transfer out to in-patient care and then post-discharge care. Within a region, the continuum extends to triaging and emergency care at a primary care facility, care during transit, and receiving at the referral hospital. Such an organisation is critical to save lives.

For example, inappropriate triaging or delay in providing emergency care before referral would make the most advanced critical care units fail. In that sense, critical care is a system and a not a standalone unit. In India, critical care is not organised as a system. The reason lies in a disintegrated healthcare system, across public and private, and across levels of care which do not speak to each other.

Within a critical care unit, the organisation structure is inappropriate. In UK, for example, ventilatory decisions are made by nurses according to set protocols. In India, all such decisions are made by doctors, who are usually anaesthesiologists or critical care specialists, who in any case are few in numbers. Some other group of paramedics, who are extremely critical for quality of care, such as physiotherapists and clinical pharmacologists, are often not available in Indian ICUs.

Many ICUs in India lack basic equipment. For example, in 10% of ICUs in Madhya Pradesh, even the basic Blood Gas Analysers were not available. Of course, much of the equipment is expensive, and raises the costs of care. ICU care in India is expensive, often comparable to the costs in North America.

A study of patients with liver disease in ICUs in Punjab revealed that average cost of ICU care to the system for each day was around Rs 1.8 lakh and about Rs 1.5 lakh to the patient. About half of the costs are for antibiotics which raise the issues of infections acquired in ICUs and of developing antimicrobial resistance.

Critical Care Units in India are highly inequitable. Colleagues at AIIMS Bhopal conducted a study to assess the status of ICUs in MP. Most of the ICUs were located in four cities, and as many as 30 out of 49 districts did not have any critical care beds. About 75% of the ICUs in the state are in the private for-profit sector, and less than 20% were in the public sector.

Critical care is expensive and is fraught with risk of hospital acquired infection and admission. Critical Care Units is best reserved for those patients who would benefit from it the most. In India, there is no clear criterion for admission to critical care units. Many patients are admitted for “monitoring” of the patients, which is wasteful.

On other hand, admission to critical care units is often used to provide end-of-life care, which is not only wasteful but also can contribute to painful and undignified last days or weeks for the patients and families. Such care is best provided at homes or hospices.

Appropriate technology

Use of appropriate technology is critical to be effective and to reduce costs. For example, in the case of Covid-19, use of high flow nasal oxygen is much more effective than mechanical ventilation when started early. Availability of a simple technology as a pulse oximeter in a primary care setting, for example, can help in early identification of respiratory failure in a child with severe pneumonia.

If oxygen concentrator is available there, providing high flow oxygen along with antibiotics, would stabilise the child and save lives. Similarly, provision of acute care for trauma, including use of Tranexamic acid at primary care level, is important to save lives.

In our own primary care settings in remote and rural south Rajasthan, for example, we have managed hundreds of children with severe pneumonia due to a combination of availability of pulse oximeter, oxygen and standard protocols.

Many people with life threatening situations therefore could be saved by instituting simple protocols, using appropriate technology and building capacities at primary care level. Even if they still require referral, they would be stabilised before referral and would reach hospitals in “better shape”, and hence would have much better prognosis.

However, that brings us to the next step of the continuum-the referral transport and care during transit. Increasing the numbers of ambulances, instituting standards of care during transit, coordination among them and hospitals, would go a long way in improving care of critically ill patients.

We can see that buying more ventilators (or adding other sophisticated solutions at the top) is not a solution to the problems we face, in times of Covid or indeed at any time.

(The writer is a paediatrician formerly with Unicef India. He is the co-founder of Basic Healthcare Services, Rajasthan, and Director, Health Services, Ajeevika Bureau, a non-profit that works for migrant workers) (Through The Billion Press)