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The Delicate Question of Inappropriate Admissions in India’s Critical Care Units

The Delicate Question of Inappropriate Admissions in India’s Critical Care Units

A critical care unit (CCU) is a specialist hospital ward that treats seriously unwell patients needing organ support and very close monitoring. Most of these patients have lung and/or heart failure. Organ support is provided by ventilators, dialysis, medications, pacemakers and other devices.

Levels of care of unwell hospitalised patients vary. Patients at risk of deterioration are monitored on medical wards. Patients with one failing organ, in a post-operative state or those who recently stepped down from ventilators require higher levels of care delivered in high-dependency units (HDU) in many nations. In the highest level of critical care, advanced lung (ventilator) support, or lung plus other organ support in multi-organ failure, is required. In India, HDUs are often amalgamated into CCUs.

Critical care saves many lives. However, it has some downsides as well. Pain due to mechanical ventilation, delirium and delusions due to altered consciousness, anxiety and post-traumatic stress disorder among survivors are common. Family members suffer anguish and post-traumatic stress disorder as well, whether a relative survives or dies.

The precise number of Indian CCU beds is uncertain. One estimate suggested India has 2.3 CCU beds per 100,000 persons. In comparison, China has 3.6, Italy has 12.5 and the US has 34.7 beds per 100,000. Another guesstimate suggested 95,000 Indian CCU beds and 48,000 ventilators, with nearly half of all beds available in just four states: Uttar Pradesh, Maharashtra, Karnataka and Tamil Nadu.

Updates from the Indian government suggest over 32,000 CCU beds have been designated for COVID-19 patients. This may be far from enough. In the pandemic, if 60% of Indians were infected over 1 year, and only one in 500 require critical care, 1.5 million Indians will need a CCU bed over a year. This will be in addition to CCU beds needed as usual for other medical conditions.

In India, one-fifth of all CCU patients die, with an average admission duration of six days. A third of those who need ventilators die.

Doctors must thus consider who may benefit and who may not prior to an admission to the CCU. No one size fits all. Each patient’s risk-versus-benefit assessment must decide admission to the CCU.

The key factor determining potential benefits, besides nature and severity of illness, is whether the illness has occurred in a previously well person or in a chronically unwell person. Frailty denotes a person’s heightened vulnerability to poor recovery after a sudden illness. Older people and those with chronic health conditions, such as cancer, and long-term heart and lung failure are considered to be more frail.

This concept is important because frail patients are 1.7-times more likely to die in the CCU, and the frailest have a 50% higher chance of being dead within 12 months even if they survive critical care, besides having worse quality of life.

Although frailty alone shouldn’t preclude critical care, it should inform patient and family decisions on opting for critical care.

Once ventilated, patients may have to stay on ventilators for a long time. And the longer a CCU stay, the lower the chance of the patient’s survival. Eighty percent of Indian CCU patients pay out of pocket for critical care, and they are faced with big hospital bills. The average cost of a CCU admission in a not-profit hospital is Rs 1.8 lakh, likely higher in corporate hospitals. Such costs have been estimated to push 3.5-6.2% of Indians into poverty each year.

Doctors should therefore consider withdrawal of life support in prolonged CCU admissions with diminishing chances of meaningful survival. The Indian Academy of Critical Care Medicine and the Indian Association of Palliative Care both endorse this principle of good end-of-life care – but only a fifth of CCU doctors are aware of such guidance and only a third apply end-of-life care principles in their clinical practice.

Some solutions

First, nationally common admission criteria and risk-benefit assessment tools incorporating frailty should be introduced in all CCUs in India. This will allow patients and their families considering critical care to make rational choices.

Second, all assessments and details of medical care must be documented in standardised electronic health records using the National Health Portal. This will allow doctors to record their assessments during CCU care, encourage best practices and limit care when appropriate.

Third, the criteria to admit post-operative patients to the CCU must be standardised. A fifth of Indian CCU admissions are post-operative. Many of these patients could potentially be managed in dedicated post-operative wards, thus freeing up CCU beds.

Fourth, all CCUs must maintain a national rolling audit of all patients via a central electronic database similar to those used by other nations. This could gather data on patient demographics, indications for critical care, treatments offered and clinical outcomes.

Fifth, a national, independent body should be constituted with members including patients, critical and palliative care associations and government officials. This body should have oversight of the national audit, publish collected data at regular intervals, share best practices and identify poorly performing units. The body could also receive, investigate and address grievances, plus recommend solutions to improve quality of clinical care.

Finally, all clinicians should be compulsorily trained on good end-of-life care and the communication skills necessary in such sensitive circumstances. It’s important for doctors to be aware of legal instruments that allow them and/or patients to stop life support and support patients’ right to die with dignity.

Critical care beds are a limited and expensive resource in India. To offer good, cost-effective critical care to appropriate patients and to protect those unlikely to benefit from critical care, a number of essential reforms must be introduced in all CCUs in India.

Dr Saif Razvi, MD, FRCP is a consultant neurologist in the UK. The views expressed here are the author’s own, and don’t represent those of the organisations the author works for.

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