Should hospitals suspend non-emergency operations?

Should hospitals suspend non-emergency operations?

Are we in mitigation stage?

Not till community spread occurs

Dr KK Aggarwal

President CMAAO, HCFI and Past national President IMA

In UK NHS Hospitals are being told to look at suspending non-emergency operations due to coronavirus.  They have asked trusts to sort their patients by risk so that routine surgery can be postponed as Covid-19 cases surge.

Freeing up capacity could also increase the number of beds needed by those with Covid-19. If you stopped doing elective surgery, you could convert theatres, you could convert resuscitation rooms, recovery areas into places where you could provide intensive care. The system could double intensive care capacity.

But in India is the right time. I do not think so. These are mitigation exercises we do when there is a community spread. We still are not in community spread stage. Even if it comes the doubling time of covid 19 will become shorter.

If that happens the following will be justifiable

§  Suspending non-urgent outpatient appointments to ensure urgent appointments were prioritised

§  Suspending non-urgent surgical admissions and procedures - but ensuring access for emergency and urgent surgery

§  Prioritising the use of non-emergency patient transport to focus on hospital discharges and ambulance emergency response

§  Expediting discharge of vulnerable patients from acute and community hospitals

§  Relaxing targets and monitoring arrangements across the health and care system

§  Minimising regulation requirements for health and care settings

§  Fast-tracking placements to home care

§  Giving permission to cancel internal and professional events, including study leave, to free up staff for preparations

§  Suspending health camps

Temporary hospital and beds made by China to tackle corona can be the answer to tackle Kota and Muzaffarpur like children deaths in future

Temporary hospital and beds made by China to tackle corona can be the answer to tackle Kota and Muzaffarpur like children deaths in future

Dr KK Aggarwal

President Confederation of Medical Associations of Asia and Oceania, Heart Care Foundation of India and Past National President Indian Medical Association

India must learn how to tackle crisis from China the way they are managing coronavirus and bird flu.

1.     Chinese authorities-imposed lockdown measures on ten cities in an unprecedented effort to contain the outbreak of corona virus

2.     The china built a specialized hospital [Huoshenshan Hospital] built in just 10 days as part of China’s intensive efforts to fight corona virus. A second facility with 1,500 beds is also being opened.

3.     As severe acute respiratory syndrome, or SARS, spread in 2003, a facility in Beijing for patients with that viral disease was constructed in a week.

In India in five days the Army fixed and handed back the collapsed foot-over bridge at Jawaharlal Nehru stadium in 2010.

Then why India never thought of building makeshift ICUs to save 100 infants who were admitted at Kota’s J.K Lone hospital and died in in December 2019 AND to save 150 children in June 2019 who died of acute encephalitis syndrome in Muzaffarpur.

Every hospital admission is associated with a risk of acquiring infection

A hospital-acquired infection (HAI), or nosocomial infection is an infection, which usually occurs 48 hours after admission. It is not related to the original condition and is neither present nor incubating at the time of admission. HAIs are also sometimes called health care–associated infections (HCAIs) to include both hospital and non-hospital settings. HCAIs occur during the process of care in a hospital or other health care facility. They can occur in any type of setting where patients receive care, even after discharge. The most common nosocomial infections include surgical wound infections, respiratory infections, genitourinary infections and gastrointestinal infections.

The most widely accepted definition of HCAIs was given by Friedman et al (BMC Med. 2014;12:40), who defined it as an infection present at hospital admission or within 48 hours of admission in patients that fulfilled any of the following criteria:

·         Received IV treatment at home, wound care or specialized nursing care through a healthcare agency, family or friends; or had self-administered IV medical therapy in the 30 days before the infection

·         Attended a hospital or hemodialysis clinic or received IV chemotherapy in the previous 30 days

·         Hospitalized in an acute care hospital for 2 or more days in the previous 90 days, or

·         Resided in a nursing home or long-term care facility.

As per WHO, of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. The endemic burden of health care-associated infection is also significantly higher in low- and middle-income than in high-income countries. More than 20% of all nosocomial infections are associated with ICU stay. In low- and middle-income countries the frequency of ICU-acquired infection is at least 2-3 fold higher than in high-income countries; device-associated infection densities are up to 13 times higher than in the USA.

Prolonged and inappropriate use of invasive devices and antibiotics, immunosuppression and other severe underlying patient conditions, failure to adhere to standard and isolation precautions are some factors that increase the risk of infection in health-care settings. Certain factors are particularly associated with resource-limited health care settings such as understaffing, overcrowding, lack of/poor knowledge, inadequate infrastructure, inappropriate use of invasive devices like catheters, lack of infection control policy. Hospital waste is also a potential source of pathogens. 

More and more diagnostic and therapeutic procedures are being performed every day. There is a risk of acquiring infection in every hospital admission or contact with a health care facility, including nursing home, rehabilitation centers or facilities that provide long-term care because during the hospital stay, the patient is exposed to pathogens, including multidrug-resistant organisms through varied sources namely, the healthcare staff, other infected patients and the environment.

Every patient must be informed about the risk of developing infection during hospital stay. Not doing so may be a ground for malpractice claim since it is unrelated to the patient’s condition which brought him/her to the hospital. Educating them on how to reduce the risk of transmission will also enhance their participation in infection control practices.

Acquiring infections in health care settings are inevitable and needs to be part of routine consent. If not done then every case of infection can end up with a media trial. Every patient and/or relatives need to know that every admission may have up to 10% risk of acquiring a new infection.  

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Hospital to charge medical representatives for visits

Medica Superspecialty Hospital in Kolkata has announced a levy of charges on medical representatives visiting its facility. The hospital has restricted the visit of a medical representative to only one day a week against a charge of Rs 350/- for three hours. Beyond this, Rs 100 per hour will be levied. A hospital in Delhi is already doing this, charging Rs 5000 per month.

The decision was aimed at discouraging MRs from visiting the hospital. The plea given is that the hospital wants to promote generic drugs.

eMedinews does not agree with this. It’s like taking away the freedom of the doctors. The knowledge about drug updates, side effects and new drug interventions that the medical representative shares is important for doctors, especially when there is no Govt. system in place by which information about banned drugs, introduction of new drugs or introduction of new equipment reaches every doctor.

MCI ethics regulation 6.8 allows a doctor to associate with pharma industry, though with some riders as follows:

“g) Affiliation:- A medical practitioner may work for pharmaceutical and allied healthcare industries in advisory capacities, as consultants, as researchers, as treating doctors or in any other professional capacity. In doing so, a medical practitioner shall always:-

(i) Ensure that his professional integrity and freedom are maintained.

(ii) Ensure that patients interest are not compromised in any way.

(iii) Ensure that such affiliations are within the law.

(iv) Ensure that such affiliations/ employments are fully transparent and disclosed.”

The MCI Ethics code does not restrict an ethical interaction between a doctor and a medical representative. The MCI Ethics Code also does not restrict academic gifts, CDs, scientific updates from pharma representatives as long as the ‘per time’ cost is less than 1000/-. Regulation 6.8.1 a has defined punishment for Gifts more than Rs. 1,000/- up to Rs. 5,000/- as ‘censure’.

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

Should there be a mourning room in the hospital?

In a survey conducted by Heart Care Foundation of India of 400 people from all walks of life, 90% of the people wanted that wishes of the dying person and dead body should be respected in the hospital setting. They said that doctors should be more compassionate and emphatic at the time of declaring a patient dead. 

 

Unless people are expecting a death, death usually comes as a shock to the family members. It is expected that the relations may be in agony, pain and even anger. Every hospital should have a mourning room where relations should be made to sit, counseled and death declared. 

 

After the death is declared, the treating doctors, nurses and hospital staff must sit with the patient’s relations, counsel them, tell them about the sequence of what happened before death and also counsel them about how to handle dead body. People also want to know the cause of death so that similar thing may not happen to another person in the family.

They also want to know if the body is infectious or not and what rituals should not be done if the body is infectious.  They also like to know about how to preserve the dead body till cremation.

They also may like to know whether a postmortem is required to know exact cause of death, which can help future family members of the family.