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Intensive care in hospital practice

  • Published at 05:12 pm June 30th, 2016
Intensive care in hospital practice

It provides special expertise and the facilities for the support of vital functions and uses the skills of medical, nursing and other personnel experienced in the management of these problems.

Intensive Care Unit in the Hospitals Houses Level 3 care (intensive care) patients as defined by the Intensive Care Society of the UK. At least, a minimum of one to one proportion of care is required, though a greater than one to one (1:1) nurse to patient ratio may may be needed to safely meet the needs of some critically ill patients. Many unstable patient requiring various simultaneous nursing activities and complex therapies used in supporting multiple organ failure can not be managed without more than 1:1 ratio of care. Intensive care should not be confused with Level 2 care, which is High Dependency Unit.

ICU care is given to patients needing advanced respiratory monitoring and support. If patients need less than 24 hour’s short term, routine postoperative ventilation who are otherwise well with no other organ dysfunction, do not fall into the category of those requiring level 3 care eg fast track cardiac surgery patients. However, if ventilation support exceeds 24 hours, or other significant organ dysfunction develops, such patient’s required level of care move into category level three. Patients needing monitoring and support for two or more organ systems, one of which may be basic or advanced respiratory support will also fall under ICU care so will the patients with chronic impairment of one or more organ systems sufficient to restrict daily activities (co-morbidity) and who require support for an acute reversible failure of another organ system. 

Now let us look at the situation of intensive care in Bangladesh. Starting the first ICU facility at the National Institute of Cardio-Vascular Disease in Dhaka in 1980 the number of ICU facility has steadily climbed up in number but unfortunately without the benefit of any regulatory body monitoring and regulating the standards and activities of such units. And not surprisingly there is severe paucity of information regarding the number, bed strength, facilities, strength of medical and nursing staffs, and cost benefits of these ICUs, so that relevant recommendation regarding quality of management can be made.

[caption id="attachment_5211" align="alignleft" width="437"]Stethoscope with national flag conceptual series - Bangladesh Stethoscope with national flag conceptual series - Bangladesh[/caption]

A study published in the Ibrahim Medical College Journal demonstrated that 90% of the ICU beds are located in the capital city of Dhaka and only 10% of them belong to Public Health Care facilities. 40% of the ICU beds had no ventilators and 60% of ICU beds had less than 1:1 patient nurse ratio. So at least more than one half to three quarter of the beds are not truly ICU beds though patients are being charged for intensive care by the hospital authorities. However, other qualitative research against the backdrop of this quantitative analysis show that the medical and nursing staff working in private hospitals' ICU either have misconception consequent on ignorance or deliberately tended to mislead researchers on the availability of equipment in their hospital ICU. 

The other very contentious issue in the Intensive Care Unit across Bangladesh is the quality of those equipment and the policy adopted and framework followed for their maintenance. Nurses and other staff rarely had formal training running those machines, they learnt by experience and death due to mechanical failure is not unheard of. The equipment did not go through routine servicing or calibration and a fault was detected only when it transpired and not surprisingly many a fault may have continued undetected for considerable time, adversely effecting treatment.

But adverse events are not limited only to problems with mechanical equipments as demonstrated by Tonima Afroze in her research paper on Patient Safety Regarding Medical Devices at ICUs in Bangladesh. Instead it spans over triviality of identification of patient to miscommunication, application of wrong medication, use of unsafe blood, blood products and ultimately to failure of system design and operations. Infection control protocol and guidelines are mostly non-existent and hand washing, the basic procedure for infection control, is hardly practiced.

Adverse outcomes have devastating consequences on patient and families. Not only is care in ICU expensive but it also brings on huge financial burden for families. Adverse outcomes leading to death and disability of patients may bring ruinous financial, social and psychological consequences.

It is imperative that regulatory framework and regulatory governing body overseeing the quality of ICU care in Bangladesh is well established and becomes effectively functional to safe guard the interest of patients and their families protecting them from devastation. It is about time that evidence based clinical practice, clinical audit (for analysing quality of patient care), risk management, adverse incidence reporting and prompt response to patient complaints and the culture of Continued Professional Development are incorporated in our health system without delay. Many of these would require investment in effective human resource development but many would require change of attitude, working philosophy and culture.

Professor Raqibul Mohammad Anwar is a practising Colorectal Surgeon at RAHETID, a global partner organisation of the Royal College of surgeons of England in Road 106, Gulshan 2, Dhaka. He also works for Bart’s and The Royal London Hospital in England, he is a retired Colonel in the Royal Army Medical Corps of the British Army and a Convener of Examinations and an Ambassador of the Royal College of surgeons of England