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