Interview

'Critical Care is Not Recognised As a Super Speciality by the MCI'

The Indian Society of Critical Care Medicine (ISCCM) was established on October 9, 1993, in Mumbai, India. The ISCCM was initially formed to bring together a group of about 25 doctors interested in critical care, on a common platform. The ISCCM has now grown to over 4,300 members and has 32 city branches all across India with its headquarters at Mumbai. It is the largest non-profit association of Indian doctors, nurses, physiotherapists and other allied healthcare professionals involved in the care of the critically ill. Nancy Singh catches up with Dr JV Divatia, President, ISCCM, on his views and plans to enhance the critical care infrastructure in India

Dr JV Divatia President, ISCCM

Please give details about the evolution of critical care field in India? How has critical care changed over the years?

Coronary care units, treating patients with heart attacks were probably the most recognised early ICUs. However, several patients needed multi-system life support, for instance, ventilatory support for the lungs, dialysis for the kidneys, drugs to maintain heart function, correction of abnormalities in blood factors, advanced monitoring of the heart, lungs and so on for diseases such as pneumonia, severe malaria, trauma or major surgery, that affected several organs apart from the heart. Only a few doctors or units were capable of doing so, notably Dr FE Udwadia's Tetanus ward at the JJ Hospital, Mumbai. A few younger doctors, with a primary background in either internal medicine, respiratory medicine or anaesthesiology, trained with such pioneers in India or abroad, and started practising critical care. As simple diseases were easily treated and lifestyle diseases increased, patients were admitted to hospitals with more complex illness, either due to resistant infections, major surgery or trauma, requiring intensive care. This trickle has now become a flood. Intensive care has evolved into a full-fledged speciality of its own, requiring knowledge and skills beyond that obtained in a basic post graduate training. ICU beds now comprise 5-25 per cent of the total bed strength in modern hospitals. Unfortunately, we do not have authentic information on the number of ICU beds in Mumbai or in India.

What are the major activities carried out by ISCCM? Who are the beneficiaries of the same?

Organising and supporting several Continuing Medical Education (CME) programmes, workshops, symposia and conferences on critical care.

The ISCCM conducts a one-year training course, Indian Diploma in Critical Care (IDCC) and two-year Indian Fellowship in critical care. Since there was no formal training available for doctors intending to practice critical care in India, the IDCC was started on 1999 to fill in this lacuna. This is now being offered in over 50 selected ICUs. The Fellowship was started two years ago. Over the years, this has created a pool of over 300 trained intensivists who are practicing in different parts of the country and contributing to better patient care. The ISCCM provides basic training in critical care for non-specialists via the Fundamentals of Critical Care Support (FCCS) and Basic Assessment and Support in Intensive Care (BASIC) courses. These courses train primary physicians and surgeons in recognition and early appropriate management of a critically ill patient before the intensivist comes into the picture.

The ISCCM brings out a quarterly journal, the Indian Journal of Critical Care Medicine, and a bimonthly newsletter, Critical Care Communications. The ISCCM has formulated standards and guidelines on various clinical and quality related issues. It is vital that the ISCCM undertakes research on topics that are relevant and important to the practice of critical care in India. The ISCCM has launched the INDICAPS or the Indian ICU Case-Mix and Practice patterns Study, a study of the patterns of diseases and practice of critical care in Indian ICUs. Over 200 ICUs have registered for this study. Another study is planned to look at infections in Indian ICUs. The ISCCM and its members have contributed to international multicentre studies, such as the SAPS3, EPIC II, the Canadian International Weaning Survey and the Nutrition survey. Some ICUs will also take part in 'Mosaics’, an observation sepsis management study across Asia. The ISCCM and the American Society are collaborating in educational programmes.

What are the changes that you wish to bring in as the President and how?

• In 2009, 15 years after its birth, the commitment of the ISCCM to its core values of promoting education and awareness of critical care remains unchanged.
• Another priority area is research relevant to India and we have initiated research studies this year to obtain data and generate solutions to our problems.
• The ISCCM has developed guidelines on several professional issues that will help in classification and accreditation of ICUs. The ISCCM will move to provide consultation and assistance to various organisations in the fields of critical care education, research, administration, quality assurance and accreditation.
• Today, the harsh reality of life is that in India, we are vulnerable not only to terror, but also to other disasters such as floods, earthquakes and disease epidemics. In addition to our usual infectious diseases, emerging diseases such as SARS and the avian flu are not far away. The ISCCM is planning to introduce the Fundamentals of Disaster Management (FDM) training programme in collaboration with the American SCCM. This programme equips doctors, ICUs and hospital staff to deal with a disaster within the context of the overall disaster management plan for the region.

What are the issues that critical care in India is grappling with and how do you as a president wish to address them?

• Critical care is not recognised as a super-speciality by the Medical Council of India (MCI). There are no MCI recognised post-graduate training courses available in India. We would like this to change so that formal critical care training is more widely available.
• Critical care is expensive. Most ICUs are in the private sector and prove expensive even for middle-class families. Greater penetration of health insurance is required. Indigenous technology and reduction in duties on drugs, equipment and consumables can help to reduce costs. Greater government spending on setting up and maintaining ICUs in public hospitals is required to cater to the increasing need for intensive care.
• Lack of trained paramedical, medical and nursing manpower, extreme variability in standards of care, lack of organised infrastructure for emergency medical services, poor structure and organisation in dealing with disasters.
• Huge magnitude of antibiotic resistance. Largely due to absence of regulation and rampant misuse of antibiotics at all levels, starting from patient self-medication to GPs, and consultants in nursing homes, hospitals and ICUs. This has made simple bugs into super-bugs that cause life-threatening infections that are either difficult or nearly impossible to treat, even with expensive antibiotics.
• Several patients receive prolonged life-supporting treatments such as artificial respiration, dialysis and the like, even when it is clear to all concerned that such treatments are futile and are merely delaying death rather than prolonging life. In fact, they cause more pain and suffering for both the patient and his family. One of the reasons that some treatments are continued is that there is no social or legal clarity on limiting futile intensive care at the end of life. The ISCCM has prepared a position paper on such issues, including provision of palliative care and comfort measures in such situations. The ISCCM organised a seminar in Delhi in 2005, and several issues related to end-of-life care were discussed. Several points from our position statement were included in a draft bill prepared by the Law Commission in 2006 (Medical treatment to terminally ill Patients, Protection of patients and medical practitioners).

What are the international standards followed in critical care and are there any Indian standards that currently exist? How do you plan to address this issue?

The ISCCM is one of the societies sponsoring the international surviving sepsis guidelines for the treatment of severe sepsis and septic shock, which is a common source of death in ICUs.

The ISCCM has prepared guidelines on several clinical and management related issues. These include prevention of vascular catheter associated infection, guidelines for the intra-hospital and inter-hospital transport of critically-ill patients, critical care delivery in intensive care units in India, guidelines for non-invasive ventilation in acute respiratory failure and limiting life-prolonging interventions and providing palliative care. By the end of May 2009, four more guidelines will be approved- design and staffing of an ICU, ICU management of common poisonings and en-venomations in India, Infection control in the ICU and Quality of care in ICU: Indicators and processes

The EMS in India is not developed as compared to the West? So what can be done for betterment of the same?

lNeeds great deal of input from government, local authorities and NGOs. Training of paramedical personnel, organisation of ambulances, retrieval and transport of patients, traffic management, co-ordination and communication between hospitals for admission depending on needs of the patient and availability of beds, 24x7 availability, facilities of trained staff, equipment and infrastructure in receiving hospitals.

Where does India stand in critical care as compared to the West? Is it at par with the West? If yes or no, why?

The best ICUs in India are easily comparable with those in the West. However, there is great variation in quality of care and standards of practice in India, so that the average care provide by the average western ICU is probably better than that in an average Indian ICU. In the West, there is public funding, so that ICU admission does not become a financial burden and patients get the care that they need. This is often not possible in our system, where ability of the patient to pay may become a limiting factor in his care.

What lessons / practices can be learnt from the west and adopted in India?

• Critical care training should be widely offered as a recognised postgraduate speciality.
• Professional societies such as the ISCCM should be actively involved in education and policy matters.
• Standards for ICUs and quality of care should be introduced and adhered to.
• Organised infrastructure for EMS.
• Well equipped and well-maintained ICUs with trained, full-time medical and nursing staff.
• Adequate funding and financial support or insurance schemes to meet expenses.
• Social and ethical consensus on end-of-life care issues in ICU patients.

nancy.singh@expressindia.com