In a first, the government has come up with guidelines for hospitals to decide on the need of a patient for treatment under the Intensive Care Unit (ICU). The guidelines have been compiled by a panel of 24 top doctors with expertise in critical care medicine. They list out the medical conditions under which a patient requires admission in ICU, like “an altered level of consciousness or if the patient needs respiratory support”. ICU care has also been recommended in cases of severe acute illness requiring intensive monitoring; medical condition which is likely to deteriorate in post-surgery cases; and for patients who have experienced any major intraoperative complication. Anyone with a living will or advanced directive against ICU care, informed refusal, disease with a treatment limitation plan and terminal-illness with medical judgement of futility have been kept out of the list of patients requiring ICU care.
Dr R K Mani, one of the experts involved in the development of the guidelines, said ICU is a limited resource. “Our recommendations are aimed to ensure its judicious use so that those who need it the most get it on priority,” he said. Dr Sumit Ray, Secretary of Indian College of Critical Care Medicine, said these are not binding and meant for only guidance. “The ICU admission and discharge criteria are broad in nature and a lot is left to the wisdom of the treating doctor,” he added. Dr Ray said most developed nations have protocol in place for triaging patients so that the resources are utilised judiciously.
India has close to 1 lakh ICU beds, mostly in private facilities and located in big cities. “Poor people who cannot afford private hospitals have to struggle, sometimes without success, to get an ICU bed,” said advocate and public health activist Ashok Agarwal. “The idea of prioritising patients for ICU care based on their condition may be good for a disaster situation but, in general, the government should work towards ensuring enough facilities to provide critical care to all,” he added. The cost of an ICU bed in private facilities is 5-10 times that of a general bed. There have been complaints in the past about needless admission to ICUs.
Experts say the new guidelines, which have already been made public by the Directorate General of Health Services (DGHS), may help assess whether ICU admission was necessary in specific cases. The guidelines also specify the criteria for discharging patients from ICU. Patients should be discharged if their physiological condition returns to near normal or baseline status or if there is reasonable resolution and stability of the acute illness that required ICU admission. Discharge is also suggested if the patient or family agrees to a treatment-limiting decision or palliative care.
In terms of manpower, the guidelines require the availability of intensivists or critical care specialists, who have specific training, certification, and experience in managing critically ill patients in the ICU. Alternatively, the guidelines suggest MBBS graduates with at least three years’ experience in ICU, with at least 50% of their time spent in the ICU.
