High bed occupancy rates in hospitals denote inferior quality of care

High bed occupancy rates in hospitals denote inferior quality of care

Dr KK Aggarwal

Padma Shri Awardee

When patients choose a hospital for treatment, they usually judge a hospital by its location, the infrastructure, the amenities and services it provides, quality of care and cost of care.

Bed occupancy rate is an indicator of hospital utilization. It is a measurement of efficiency and effectiveness of a hospital. Bed occupancy rate of a hospital varies at any given point of time. While a ‘full house’ would perhaps appear to be most satisfying, it is not actually so, especially for a hospital.

According to the Australian Medical Association, Irish Medical Organisation, Australasian College for Emergency Medicine and NHS England, a bed occupancy rate above 85% or ‘overcrowding’ is considered to have an adverse effect on patient safety and the operational efficiency of the hospital.

High bed occupancy rate increases the risk of spread of hospital-acquired infections such as MRSA and Clostridium difficile via cross transmission. Such hospitals also run the risk of bed shortages when they are most needed, such as during outbreaks, or disasters. 

Overcrowding means not enough beds for patients from emergency department. A long waiting time for transfer to the appropriate inpatient bed increases mortality and chances of adverse events.

Overcrowding compromises quality of care. Medications may not be administered in time; the chances and frequency of errors increase as well.

Hospitals, in particular Govt. hospitals, have a policy of not denying admission to any patient, even if this means allotting the same hospital bed to two inpatients, or sometimes even three in pediatric wards. The outcome is an inferior quality of care, at the same time, it also creates an impression that we can manage even with inadequate infrastructure and resources available to us.

No hospital, whether Govt. or private, should have more than 85% bed occupancy rate.  Admitting 150 patients in a 100-bedded hospital is not correct. This means that for 50 extra patients, you are compromising care of 100 patients as resources are shared for a much larger number of patients than meant for.

This would also be applicable to govt. hospitals, if they over admit patients in view of the recent govt. notification, which makes it mandatory for all clinical establishments, chemists/pharmacists to notify every case of TB or else face penal provisions under sections 269 and 270 of the Indian Penal Code

Universal Healthcare for All

Dr KK Aggarwal

Recipient of Padma Shri

There is a wide gap in the availability of healthcare service in the country. On one hand, India is fast becoming the hub of medial tourism, whereas in a sharp contrast, healthcare including essential healthcare is still out of reach for many of her citizens.

The private sector provides 80% of healthcare in the country today, while only 20% is by govt. sector. This is because the govt. spends very little on health. Currently, India spends just 1% of its gross domestic product (GDP) on health and is ranked at 180th position out of 192 countries on this. Without spending at least 5-6% of the GDP on health, the basic healthcare needs of the population cannot be fulfilled. Although the National Health Policy, 2017 has provided for increasing public expenditure on health to 2.5% of GDP from the current ~1%, it is still very inadequate to provide universal healthcare.

The highly priced private healthcare is inaccessible to many; yet many seek healthcare in the private sector, and often find themselves in financial trouble.

Very few people in the country have health insurance coverage. India has one of the highest out of expenditures on health in the world, which is over 60%, which contributes to poverty due to exorbitant health expenses resulting in further inequity in health services.

Universal health coverage is the answer to affordable healthcare of quality in developing countries like India. The goal of universal health coverage is to ensure that all people receive the health services they need without suffering financial hardship when paying for them (WHO Online Q&A, December 2014). Universal healthcare provides Affordable, Adequate, Accessible, Available, Appropriate and Accountable quality and safe healthcare to the public.

Achieving universal health coverage is a target under the Sustainable Development Goal (SDG 3) “to achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (3.8)”.

The World Health Organization (WHO) has chosen “Universal health coverage: everyone, everywhere” as the theme of the World Health Day this year.

Every citizen in the country has a right to receive safe and quality medical treatment. Right to health and medical care has been recognized as a fundamental right covered by Article 21 by the Hon’ble Supreme Court of India.

It is the constitutional duty of the govt. to provide quality healthcare for all. In this day and age, when medicine has made tremendous advances, nobody should die just because they cannot afford treatment.

Stop Press Breaking News

IMA Resolutions at Mahapanchayat

1. Medical students to go on strike on 2nd April 

2. IMA members to go on indefinite strike if NMC is passed by the government

Ask Dr KK: What is the number one cancer in India?

The number one cancer in females is cervix in rural and breast in urban area. In males is  is oral cavity in rural and lung in the urban area.

Ask Dr KK:What is the number one cancer in India?

The number one cancer in females is cervix in rural and breast in urban area. In males is  is oral cavity in rural and lung in the urban area.

Ask Dr KK:How often to repeat BMD test for osteoporosis?

• Assessment of fracture risk in all adults is important.

• BMD-independent risk factors are advanced age, previous fragility fracture, glucocorticoids, risk of falls, smoking, alcohol, and family history of fracture. 

• Screen with BMD in all women 65 years of age and older

• Screen with BMD in postmenopausal women less than 65 years if one of the above risk factors is present

• Do not perform 

• routine BMD measurements in premenopausal women 

• Do not perform routine BMD measurements in all men.

• Measure BMD in men who have clinical manifestations of low bone mass, such as radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height, as well as in those on long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, hyperthyroidism, and intestinal disorders

• For screening BMD use DXA

• Go for DXA of hip and spine

• Measurement of the hip alone could be sufficient in older individuals. 

• In women and men with low bone mass (T-score -2.00 to -2.49) at any site or who have risk factors for ongoing bone loss (steroid use, hyperparathyroidism) do follow-up BMD every two years as long as the risk factor persists 

• In women 65 + years at baseline with low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for accelerated bone loss, go for follow-up DXA in three to five years

• In women 65 years + of age with normal or slightly low bone mass (T-score -1.01 to -1.49) at baseline and no risk factors for accelerated bone loss go for follow-up DXA in 10 to 15 years 

• A 65-year-old woman with a femoral neck BMD T-score of -1.01 to -1.49 and no clinical risk factors for fracture has 10-year absolute risk of hip fracture of only 0.9 percent.[Source Uptodate] 

Ask Dr KK: Should I go for a knee replacement?

A: Yes if  

1. I am no longer able to do my routine work without help

2. I have pain that keeps me awake at night despite the use of drugs

3. I have pain that keeps me from being able to walk or bend over

4. I have pain that isn’t relieved by rest

5. I have pain that is not responding to non-surgical approaches.

6. I have been told that less-complicated surgical procedures are unlikely to help.

7. The disease osteoarthritis is wearing me down physically, emotionally, and mentally.

8. I am suffering from severe side effects from the drugs 

9. Advanced arthritis is demonstrated on my test

10. If significant joint damage has occurred on my tests. 

About the author: Dr K K Aggarwal is Padma Shri and Dr B C Roy National Awardee, President Heart Care Foundation of India and National Vice President Elect IMA [ blog.kkaggarwal.com]

Ask Dr KK: Why it is said to avoid adding sugar and milk to black tea

Black tea and coffee are the best. Also as per Ayurveda never add sugar taste to astringent and bitter taste. It will neutralize its benefits.  Also do not add artificial sweeteners they will have the same effect.

Ask Dr KK:A person last week was told is executive heart check up is normal. He died next week suddenly. How can it be possible?

A: Sudden death is invariably due to heart attack which occurs after a soft vulnerable blockage in the heart artery suddenly ruptures. Treadmill test can only detect blockages of up to 70%. The blockages which are vulnerable to rupture are the ones which are less than 50%. Now days the executive health checks have no meaning as they only detect clinically evident diseases. Analysis and managing risk factors are more important than evaluation with a treadmill test. If you have risk factors you are at risk and manage them irrespective of your reports. We treat the patient and not the reports.

Ask Dr KK: How often to repeat BMD test for osteoporosis?

Ask Dr KK: How often to repeat BMD test for osteoporosis?

• Assessment of fracture risk in all adults is important.

• BMD-independent risk factors are advanced age, previous fragility fracture, glucocorticoids, risk of falls, smoking, alcohol, and family history of fracture. 

• Screen with BMD in all women 65 years of age and older

• Screen with BMD in postmenopausal women less than 65 years if one of the above risk factors is present

• Do not perform 

• routine BMD measurements in premenopausal women 

• Do not perform routine BMD measurements in all men.

• Measure BMD in men who have clinical manifestations of low bone mass, such as radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height, as well as in those on long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, hyperthyroidism, and intestinal disorders

• For screening BMD use DXA

• Go for DXA of hip and spine

• Measurement of the hip alone could be sufficient in older individuals. 

• In women and men with low bone mass (T-score -2.00 to -2.49) at any site or who have risk factors for ongoing bone loss (steroid use, hyperparathyroidism) do follow-up BMD every two years as long as the risk factor persists 

• In women 65 + years at baseline with low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for accelerated bone loss, go for follow-up DXA in three to five years

• In women 65 years + of age with normal or slightly low bone mass (T-score -1.01 to -1.49) at baseline and no risk factors for accelerated bone loss go for follow-up DXA in 10 to 15 years 

• A 65-year-old woman with a femoral neck BMD T-score of -1.01 to -1.49 and no clinical risk factors for fracture has 10-year absolute risk of hip fracture of only 0.9 percent.[Source Uptodate] 

Ask Dr KK: I am having cough, nasal discharge and sore throat. There is no fever. Is it flu?

Ask Dr KK: I am having cough, nasal discharge and sore throat. There is no fever. Is it flu?

A: No fever no flu is the mantra. No fever means allergic rhinitis.

#Ask Dr KK Swine flu kills 95 in north India since January 1. Oh My God I a scared.

Dr KK: Do not panic about the deaths. 

Hong Kong Study: The overall attack rate of pandemic H1N1 influenza A between April and December 2009 was 10.7 percent. 

Case-hospitalization rates were 0.47 to 0.87 percent among individuals aged 5 to 59 years. 

Case-ICU rates were 7.9 cases per 100,000 infections in children aged 5 to 14 years and 75 cases per 100,000 infections in adults aged 50 and 59 years. 

Case-fatality rates were 0.4 cases per 100,000 in children aged 5 to 14 years and 26.5 cases per 100,000 in adults aged 50 to 59 years.

Ask Dr. KK:My triglyceride levels are 300 mg%. Do I need a drug?

Answer: For first three months, try not taking white rice, white maida and white sugar. Stop alcohol if you take. Recheck after three months. There are 90% chances that your triglycerides will become normal.

Ask Dr KK: I am an asthmatic. Do I need steroid inhalers? My age is 19 years.

Ans: Remember the formula of 2. If you get asthma attack twice in a month in night or twice in a week in day time or if you consume more than 2 canisters of inhaler in a year, you need continuous treatment with bronchodilator along with an inhaled steroid.

#AskDrKK: Who is not fit to drive?

People who snore in the night should have medical fitness before they can become commercial drivers.

#AskDrKK: How to calculate platelet counts from peripheral smear?

#DrKKAnswers:
A: There are two methods: Platelet count per uL =
1. Average number of platelets per oil immersion field multiplied by 20,000.
2. Average number of platelets per oil immersion field multiplied by Hb (g/dL) and then multiplied by 1,000.

Bomb blast injuries are always hollow organ injuries; Delhi Blast Update

1.      Primary blast injuries are the injuries to the hollow gas-filled organs like the lungs, ear drum or intestines leading to their rupture. These occur as a direct result of the impact of the over pressurized blast wave on the body.

2.       Secondary blast injuries occur due to flying debris and bomb fragments leading to penetration or penetrating injuries such as to the eyes.

3.       Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures as a result of the fall.

4.       Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important triage to manage blast injuries is not to waste energies and resources on patients with non-serious injuries.  The first thing is to check for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non-serious injury.

All patients exposed to a blast must have eardrum examination as the first step. If the ear drums are intact, the patient can be discharged with first-aid treatment. If ear drum is ruptured, an X-ray chest should be done immediately. All such patients should be observed for eight hours as primary blast injuries are notorious for delayed presentation.

Doctors should therefore focus only on two exams: otoscopic ear exam and pulse oximetry. Blast lung injury is unlikely without tympanic or ear membrane rupture. This is used as a screening procedure for admitting a patient. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.

Half of all initial casualties seek medical care over first hour. Double this number after one hour and you will know the total casualties. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.

Always expect upside down triage as the most severely injured arrive after the less injured who self-transport to the closest hospitals.

With the increasing use of explosives in terrorist events in our country in recent times, doctors, especially Emergency Doctors, should undergo orientation training every six months so that they are prepared and better equipped to manage several casualties all at one time.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Chairman Ethics Committee Delhi Medical Council, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association and Past Academic and Research Wing Heads IMA.

#AskDrKK: Starting enteral nutrition in a patient on ventilator

#DrKKAnswers: Starting enteral nutrition with a low infusion rate improves tolerability, compared to initiation at the target rate. A randomized study of 200 mechanically ventilated patients showed that enteral feeding (at the target rate or at 10 mL/hr for six days before being incrementally increased to the target rate) showed no differences in mortality, ventilator-free days, or ICU-free days, but the group that began at the target rate had more episodes of elevated gastric residual volumes and a trend toward more diarrhea.
Source: Crit Care Med 2011; 39:967.

#AskDrKK: Ventilator induced Diaphragmatic atrophy

#DrKKAnswers: Controlled mechanical ventilation can lead to a very rapid type of disuse atrophy involving the diaphragmatic muscle fibers.
An observational study found that diaphragmatic strength decreased progressively during mechanical ventilation and that long-term (>24 hours) mechanical ventilation was associated with diaphragmatic muscle injury, atrophy, and proteolysis compared to short-term mechanical ventilation (2-3 hours)

Source: Am J Respir Crit Care Med 2011; 183:364.

#AskDrKK: How serious is Ventilator-associated tracheobronchitis?

#DrKKAnswers: Ventilator-associated tracheobronchitis VAT has the same clinical implications as ventilator-associated pneumonia (VAP). An observational study of 28 patients with VAT and 83 patients with VAP showed that VAT groups had a similar length of intensive care unit stay, length of hospital stay, duration of mechanical ventilation, survival rate to discharge, need for tracheostomy, and need for antibiotics.

Source: Chest 2011; 139:513.

Why no leafy vegetables in Shravan and curd is taken in Bhadon month

http://www.itimes.com/users/iti475269/blogs

              "Savan me saag nahi, bhado me dahi nahi, ashwin me doodh nahi, kartik me tel nahi"

It is a traditional Ayurveda saying that one should not take green leafy vegetables in the month of Shravan, curd (yogurt, dahi) in the month of Bhadon, milk in the month of Ashwin and butter milk (mahi, matha), pulses and oil in the month of Kartik.

To answer these questions, we need to understand the concept of Vata, Pitta and Kapha from Ayurveda. In terms of modern medicine, Vata represents movement; Pitta metabolism and Kapha structure and water.

 As per Ritucharya (seasonal routine), Vata or movement functions in the body are aggravated in Varsha Ritu (rainy season) which coincides with Shravan and Bhado months. In this month Pitta functions starts accumulating.

 Pitta or metabolism is aggravated in Sharad Ritu (Ashwin and Kartik months) and Kapha in the Vasant Ritu (Chaitra and Vaisakha).  In Sharad Ritu when Pitta gets aggravated the Kapha is accumulating.

In the month of Shravan, as Vata or movement function is aggravated, any food item which aggravates Vata or movement will cause harm to the body. Ground leafy vegetables increase Vata, therefore, are prohibited in the month of Shravan. As per the modern medicine, being a rainy season, most of the ground worms will also come to the surface and infect the leafy vegetables. This is another reason why leafy vegetables are harmful to the body in the month of Shravan.

In Varsha Ritu (Rainy season), Vata is aggravated but Pita has stated accumulating which gets aggravated in Sharad Ritu. Therefore in the month of Bhadon, it is advised to eat fewer yogurts (dahi) as anything fermented aggravates Pitta. Though Ayurveda talks that curd should not be eaten in the month of Bhadon season, from allopathic point of view, it should be true for all fermented foods including alcohol, dosa, idli or dhokla etc.

Kapha producing substances like milk and butter milk are avoided in Sharad Ritu as at that time Kapha is accumulating and Pitta is aggravated.

As per the Ayurveda in the month of Shravan and Bhadon, the digestive fire is weak and, therefore, any substance which can obstruct the digestive channels should be avoided and curd is one of them.

Ayurveda also prohibits eating curd in the night throughout the year as after 6 pm the digestive fire in the body is weak, Kapha is predominant and any curd food taken at that time will block the digestive channels.

Naturopathy is in agreement with Ayurveda but Allopathy is silent on this issue.  Without going into the details of the subject the conclusion is to avoid eating curd in the month of bhadon.