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Tele ICU: Scope in India
Dr. N. RamakrishnanAB(Int Med), AB (Crit Care), AB (Sleep Med),
MMM, FACP, FCCP, FCCM, FICCMDirector, Critical Care Services, Apollo Hospitals, Chennai
Managing Director, InTeleICU ™
Disclosures
• Have been providing Tele-ICU services for the US hospitals for over 3 years
• Managing Director of InTeleICU™ - providing remote monitoring services in India
• Professional consultation provided to Industry for Tele-ICU services
• Believe in the concept!
Healthcare Scenario
1. 1.5 beds per 1000 (WHO norm is 3.3 per 1000)• India will add 660,000 hospital beds by
2015 predominantly driven by large private hospitals & Nursing homes
2. 284 Medical Colleges (136 are Private)
3. Approx 23,000 medical graduates per year
4. 2010 McKinsey Report • India urgently needs 2 Lakh doctors &
5 Lakh nurses• 6.5 lakh doctors required to maintain a
ratio of 1 to 1.25 doctors per 1000• 18.7 lakh nurses required to maintain a
ratio of 2.6 per 1000
Chennai Critical Care Consultants
ICUs are complicatedDonchin Y Donchin Y et alet al (2003). Quality Safety Health Care; 12:143 (2003). Quality Safety Health Care; 12:143
Engineers observed patient care in ICUs for twenty-four hour periods
They found that the average patient required a hundred and seventy-eight individual actions per day
e.g., administering a drug, suctioning, ventilator decision making
RNs and MDs were observed to make an error in only one per cent of these but:
An average of two errors a day with every patient.
Impact of Adverse EventsGarrouste OM Garrouste OM et alet al (2008). (2008). Critical Care MedCritical Care Med; 36:2041; 36:2041
39.2% of ICU patients with at least one adverse event (AE)22.7% with more than two
AEs associated with death Odds ratioPrimary bacteremia (including cath-associated) 2.92Secondary Bacteremia 5.7Non-bacteremic pneumonia 1.69Deep surgical site infection 3.0Pneumothorax 3.1GI Bleeding 2.6
Knowing vs. Doing the Right Thing Young MP et al (2004). Young MP et al (2004). Critical Care MedicineCritical Care Medicine; 32:1260; 32:1260
Intensivists are familiar with the “ARDSNet” guidelines for lung protective strategies.
How often was it being followed for patients in the ICU?Evaluated the ventilator settings and the patient to see if it was being followed
85% of ICU physicians believed they were using lung protective strategies11% of patients were receiving Vt < 8 ml/kg PBW
How can compliance with “Best Practices” be insured?
Puzzle of the ICU
You have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right
despite some monitor’s alarm going off despite the patient in the next bed crashingdespite a nurse poking his head around the curtain to ask whether
someone could help “get this lady’s heart rate under 170.”
So how do you actually manage all this complexity?
Be organized, Get Help!
Every complicated task in the US military has a “Protocol Authorization”
Deviations are NOT allowed
Airline Industry“Go - no go”
MedicineProtocols
Historically, not our modelExtra pair of eyes and help to implement best practice
Lack of standards/ Laws / regulations
Shortage of trained manpower
ICU care is primitive or non-existent at district hospitals in rural India
Lack of any grading of ICU’s in critical care
The number of ICU beds available is disproportionately low, both in private as well as public hospitals.
CRITICAL CARE SHORTFALLS
Most hospitals today have difficulty in meeting the demand for quality Critical Care due the following factors:
Lack of trained Intensivists and Nursing staff.
Round the clock coverage
Unavailability of concrete statistics/data relating Medical Errors, Length of Stay, etc.
Lack of use of technology and available knowledge
CRITICAL CARE CHALLENGES
Critical Care Workforce - USA
• COMPACCS Study– Committee on Manpower for Pulmonary & Critical Care Societies– Angus et al. JAMA 2000– Predicted progressive shortage of manpower in the specialities over 30 years– Aging of population will create a demand for care that would outpace supply
• Critical Care Workforce Partnership– ACCP, ATS, SCCM & AACN– Framing Options for Critical Care in the United States (FOCCUS)
• Working with Public Policy Makers– Critical Care Medicine Crisis – A call for Federal Action– Issue addressed by Senate & Department of Health & Human Services
Critical Care Workforce
• Australia– Document created by Australian Medical Workforce Advisory Committee– Suggested Training Output should increase– Aging of population will create a demand for care that would outpace
supply
• United Kingdom– Kishen R – Editorial – “Intensive Care Workforce – Back to the Future’ –
JICS 2008– Are we back to the era of Polio outbreak? (1952)
Critical Care Workforce - India
• Intensivist/s• Resident doctors• Nurses,• Respiratory Therapists• Nutritionist• Physiotherapist• Technicians• Computer programmer/IT support• Biomedical Engineer• Clinical Pharmacist• Social worker or counsellor• Other support staff.
– Housekeeping, guards and Class IV.
Critical Care Nursing
• 1:1. nursing for Ventilated or MOFS patients is desirable – In no circumstance the ratio
should be < 2 nurses for three patients as this will affect outcome immensely
• 1:2 to 1:3 nurse patient ratio is acceptable for less seriously sick patients who do not require above modalities
– ISCCM Guidelines
Shortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in India
TECHNOLOGY BASED SOLUTION
Tele-ICU
Assists hospitals by providing 24 x 7 coverage remote monitoring assistance to the bed side teams
Episodic vs ContinuousA comprehensive critical care solution beyond walls
Remote Monitoring Solutions Remote Monitoring Solutions Remote Monitoring Solutions Remote Monitoring Solutions
• Providing remote ICU Management Services to Hospitals in the US
• Acute shortage of intensivist in US
• Urban & Semiurban Hospitals, Rural Centers, Government facilities do not have uniform technology – which necessitates customization of solution• Cost effective solution
Powering Critical Care
INTELEICUINTELEICUINTELEICUINTELEICU
• Specialist driven critical care beyond walls
• Access to services 24 X 7 (Critical Care – Anywhere, Anytime)
• Specialist driven critical care beyond walls
• Access to services 24 X 7 (Critical Care – Anywhere, Anytime)
Parameter ICUs in US ICUs in India
Extent of technological penetration Very high level Low to Medium levels
Definition of tasks, roles and responsibilities Well defined & documented Not as defined as in the US
Extent of human interface for Tele ICU Management
Less; thanks to live feeds of medical data from bed side of
patientVery high; Significant paper data
Need / Problem AreasIncreasing need for 24 X 7 support to establish best practices round the clock
ICUs in Metros – Value added Service
For ICUs in non-metro areas & those in Metros without round the clock
trained intensivists Required service
TYPICAL TELEMEDICINE SYSTEM
TELEICU MODEL