Download Dr. Lava N Joshi- Critical care

Critical Care:
Career Options &
Opportunities
Dr. Lava N Joshi
MD ( Cardiology )
Consultant Cardiologist
Om Hospital and Research Center
INTRODUCTION
 The term “Intensive Care” refers to the great amount of
care that a critically ill patient requires in comparison to
a regular and less sick patient.
 The term Intensive Care unit refers to separate ward in
the hospital, which caters such sicker group of patients.
•
The concept of Intensive care was put
forward by Florence Nightingale after the
Crimean war when she started treating
sicker patients in a separate area.
 Following the Polio epidemic in 1952, Dr. Bjorn Aage
Ibsen, a Danish Anesthetist , started the world’s first ICU
in Copenhagen in 1953, when he started treating
respiratory paralysis polio patients by intubating and
ventilating them.
Then after, ICU started flourishing all over the world with
the advancement of modern technologies and electronic
revolution.
At that time ICU used to function as a multidisciplinary unit
with involvement of various subspecialties.
 Since early 1990s, after the establishment of Critical
Care Medicine, the branch of medicine that deals with
study of these critically ill patients, ICUs started
functioning as separate department.
NEPALESE SCENARIO
 In Nepal, the first ICU started in 1973, at Bir Hospital, as
a five bed medical ICU.
 This ICU was established in 1970 when king Mahendra
developed heart problem.
 This was the only ICU in the country for almost 20 years.
Marasini B R, Health and Hospital development in Nepal, past and
present ,JNMA 2003.
 Another ICU became functional after the development of
TUTH at IOM in 1990 and was a six bed mixed medical
and surgical ICU.
 Then after , with the increasing demands of ICU beds,
critical care slowly progressed and has reached its
current status.
 Now almost all hospitals in the country have few ICU
beds, accounting to a total of around 500 ICU beds in
the country.
 A survey of ICU beds in 51 hospitals within Kathmandu
Valley with 50+ bed capacity, showed
 21.6 % in Govt hospital
 15.7 5 in Community hospital
 62.7% in Private Hospitals
Shrestha RR,Vaidya PR,Bajracharya GR, A survey of adult intensive care units in Kathmandu Valley
Postgrad med J NAMS, 2011
 There were 48 intensive care units , with total of 331 ICU
beds, which comprises of 4.7 % of all hospital beds.
 Facility for mechanical ventilation was available only in
161 ( 2.3 %) of total hospital beds
 Considering population of around 20 million in 2011,
there are only 15.2 ICU beds per 100,000 population
and only 7.2 ICU beds with ventilator per 100,000
population.
FACILITIES IN ICU
 Most ICU have non-invasive facilities with ECG, NIBP and
pulse oximetry.
 50 % have intra-arterial BP monitoring.
 CV catheterization is done in almost all ICU even outside the
valley.
 Blood gas analyzers are available in 10 ICUs, portable X-ray
in 28 ICUs, bedside USG and Echo in only few ICU
 Mechanical ventilators are available in almost all ICUs in
Nepal.
 Renal replacement therapy is available in only few ICU.
ICU AUDIT
Magh 1st 2070 - Jestha 2072
 The new ICU was inaugurated on 1st of Magh 2070.
 Om ICU is known for diversity of disease.
 Since then the total admissions during this period is 1351.
 Among them a total of 214 ( 15.8%) mortalities occurred
“Age Distribution”
398
400
350
300
250
200
150
100
50
0
119
111
155
180
213
67
0
0
0
0
31
-4
41
-5
51
-6
61
-7
>7
0
0
21
-3
20
-N
ov
10
-J
an
16
“Systemic Disease Categorization
367
271
176
155
rn
9
Bu
ni
ng
o
Po
i
so
th
e
20
cr
in
ro
En
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ph
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Ne
Ob
co
na
e/
On
Gy
GI
T
32
89
86
51
Or
95
CN
S
Re
sp
CV
S
400
350
300
250
200
150
100
50
0
“Duration of stay”
Duration of ICU Stay
9.13
2.81
1--3
18.07
4--6
7--10
70.18
>10
15
10
Magh
F al g u
n
Ch a i
tra
Bais
akh
Je s t h
a
Asad
Shra
w an
Bh a d
ra
A soj
Karti
k
Mang
sir
Pous
h
Magh
F al g u
n
Ch a i
tra
Bais
akh
Je s t h
a
“Ventilator Used”
25
20
20
17
19
17
15
8
6
18
9
10
13
10
14
Ventilator used
Improved
Deceased
14
12
11
9
5
0
Global challenges
 Critical care is costly
 With increase in life expectancy and improved overall
care of patients, the need for ICU bed is increasing
 Crit Care Med 2010;38:65-71
 The key challenge for the future will be to provide
adequately trained intensivists as there is a predicted
shortfall.
 Crit Care Med 2008;36:1350-1353
Training programs in Nepal
 DM program in Critical Care Medicine started at
Institute of Medicine, Tribhuvan University from October
2013. Formal collaboration with Royal College of
Physicians and Surgeons of Canada (RCPSC)
 1 candidate in first batch
 2 in second batch
 JSAN 2014;1(2)
 DM Pulmonary Critical Care and Sleep medicine, started
in Bir Hospital NAMS in 2012
 Introduced in BPKIHS Dharan in 2014
 JSAN 2014;1(2)
Levels of ICU
Level III:
 Tertiary referral unit
 Should be capable of providing comprehensive critical care
including complex multi-system life support for an indefinite
period
 Involvement in education and research
 All patients to be referred to attending ICU specialist for
management
 Requirements of Level III ICU:
 At least 8 staffed and equiped beds
 Sufficient clinical workload and case-mix to maintain clinical
expertise
 Should manage more than 400 mechanically ventilated patients
per annum
 Run by medical director – full time commitment to the operation
of ICU and trained in Intensive Care Medicine
 Minimum of 1:1 nursing for ventilated and other similarly
critically ill patients and 1:2 nursing for lower acuity patients
(clinically determined)
 Defined protocols, admission, discharge and referral policies
 Suitable infection control and isolation procedures and facilities
 24 hours access to pharmacy, pathology, operating theatres and
imaging services
Level II:
 Capable of providing general intensive care including complex
multisystem life support
 Capable of providing mechanical ventilation, renal replacement
therapy and invasive cardiovascular monitoring for an indefinite
period of time
 Should have arrangement for patient referral to tertiary hospital
when appropriate specialty support (neurosurgery,
cardiothoracic surgery) is not available
 At least 6 staffed and equipped beds
 More than 200 mechanically ventilated patients per annum
 Run by medical director – full time commitment to the operation
of ICU and trained in Intensive Care Medicine
 Nursing requirement similar to Level III
Level I:
 Capable of providing immediate resuscitation and short term
cardiorespiratory support for critically ill patients
 Major role in monitoring and preventing complications in “at
risk” medical and surgical patients
 Capable of providing mechanical ventilation and simple
cardiovascular monitoring for at least several hours.
 Should have established referral relationship with Level II and III
units
CHALLENGES
 Lack of governing bodies to monitor the services, quality and
facilities required to run an ICU.
 Lack of certified Intensivists to manage and run the ICUs
 Lack of certified training courses for the allied health staff.
 High cost of treatment, which has to be borne by the patient or
their family.
 Unavailability of medications, drugs, and equipment .
 Apart from litigation and legal claims, health care in Nepal also
experiences vandalism, physical threats and even blackmailing.
THANK YOU ALL FOR
YOUR KIND ATTENTION.