mHealth Chennai Summit 2015 - Junior Doctors Forum

1. Tele ICU: Scope in India
Dr. N. Ramakrishnan
AB(Int Med), AB (Crit Care), AB (Sleep Med),
MMM, FACP, FCCP, FCCM, FICCM
Director, Critical Care Services, Apollo Hospitals, Chennai
Managing Director, InTeleICU ™

2. Disclosures
• Have been providing Tele-ICU services for the US
hospitals for over 3 years
• Managing Director of InTeleICU™ - providing
remote monitoring services in India
• Professional consultation provided to Industry for
Tele-ICU services
• Believe in the concept!

3. Healthcare Scenario
1. 1.5 beds per 1000 (WHO norm is
3.3 per 1000)
• India will add 660,000 hospital beds by
2015 predominantly driven by large
private hospitals & Nursing homes
1. 284 Medical Colleges (136 are
Private)
2. Approx 23,000 medical graduates
per year
3. 2010 McKinsey Report
• India urgently needs 2 Lakh doctors &
5 Lakh nurses
• 6.5 lakh doctors required to maintain a
ratio of 1 to 1.25 doctors per 1000
• 18.7 lakh nurses required to maintain a
ratio of 2.6 per 1000
Chennai Critical Care
Consultants

4. ICUs are complicated
Donchin YDonchin Y et alet al (2003). Quality Safety Health Care; 12:143(2003). Quality Safety Health Care; 12:143
Engineers observed patient care in
ICUs for twenty-four hour periods
They found that the average patient
required a hundred and seventy-eight
individual actions per day
e.g., administering a drug,
suctioning, ventilator decision
making
RNs and MDs were observed to make
an error in only one per cent of these
but:
An average of two errors a day
with every patient.

5. Impact of Adverse Events
Garrouste OMGarrouste OM et alet al (2008).(2008). Critical Care MedCritical Care Med; 36:2041; 36:2041
39.2% of ICU patients with at least one adverse event (AE)
22.7% with more than two
AEs associated with death Odds ratio
Primary bacteremia (including cath-associated) 2.92
Secondary Bacteremia 5.7
Non-bacteremic pneumonia 1.69
Deep surgical site infection 3.0
Pneumothorax 3.1
GI Bleeding 2.6

6. Knowing vs. Doing the Right Thing
Young MP et al (2004).Young MP et al (2004). Critical Care MedicineCritical Care Medicine; 32:1260; 32:1260
Intensivists are familiar with the “ARDSNet” guidelines for lung protective
strategies.
How often was it being followed for patients in the ICU?
Evaluated the ventilator settings and the patient to see if it was being followed
85% of ICU physicians believed they were using lung protective strategies
11% of patients were receiving Vt < 8 ml/kg PBW
How can compliance with “Best Practices” be insured?

7. Puzzle of the ICU
You have a desperately sick patient, and in order to have a
chance of saving him you have to make sure that a
hundred and seventy-eight daily tasks are done right
despite some monitor’s alarm going off
despite the patient in the next bed crashing
despite a nurse poking his head around the curtain to ask whether
someone could help “get this lady’s heart rate under 170.”
So how do you actually manage all this complexity?

8. Be organized, Get Help!
Every complicated task in the US military has a “Protocol
Authorization”
Deviations are NOT allowed
Airline Industry
“Go - no go”
Medicine
Protocols
Historically, not our model
Extra pair of eyes and help to implement best practice

9. Lack of standards/ Laws / regulations
Shortage of trained manpower
ICU care is primitive or non-existent at district hospitals in rural India
Lack of any grading of ICU’s in critical care
The number of ICU beds available is disproportionately low, both in
private as well as public hospitals.
CRITICAL CARE
SHORTFALLS

10. Most hospitals today have difficulty
in meeting the demand for quality
Critical Care due the following
factors:
Lack of trained Intensivists and
Nursing staff.
Round the clock coverage
Unavailability of concrete
statistics/data relating Medical
Errors, Length of Stay, etc.
Lack of use of technology and
available knowledge
CRITICAL CARE CHALLENGES

11. Critical Care Workforce - USA
• COMPACCS Study
– Committee on Manpower for Pulmonary & Critical Care Societies
– Angus et al. JAMA 2000
– Predicted progressive shortage of manpower in the specialities over 30
years
– Aging of population will create a demand for care that would outpace
supply
• Critical Care Workforce Partnership
– ACCP, ATS, SCCM & AACN
– Framing Options for Critical Care in the United States (FOCCUS)
• Working with Public Policy Makers
– Critical Care Medicine Crisis – A call for Federal Action
– Issue addressed by Senate & Department of Health & Human Services

12. Critical Care Workforce
• Australia
– Document created by Australian Medical Workforce Advisory Committee
– Suggested Training Output should increase
– Aging of population will create a demand for care that would outpace
supply
• United Kingdom
– Kishen R – Editorial – “Intensive Care Workforce – Back to the Future’ –
JICS 2008
– Are we back to the era of Polio outbreak? (1952)

13. Critical Care Workforce - India
• Intensivist/s
• Resident doctors
• Nurses,
• Respiratory Therapists
• Nutritionist
• Physiotherapist
• Technicians
• Computer programmer/IT support
• Biomedical Engineer
• Clinical Pharmacist
• Social worker or counsellor
• Other support staff.
– Housekeeping, guards and Class IV.

14. Critical Care Nursing
• 1:1. nursing for Ventilated or MOFS
patients is desirable
– In no circumstance the ratio
should be < 2 nurses for three
patients as this will affect
outcome immensely
• 1:2 to 1:3 nurse patient ratio is
acceptable for less seriously sick
patients who do not require above
modalities
– ISCCM Guidelines

15. Shortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in IndiaShortage of Intensivists (Critical Care Specialists) in India

16. TECHNOLOGY BASED SOLUTION
Tele-ICU
Assists hospitals by providing 24 x 7 coverage remote monitoring
assistance to the bed side teams
Episodic vs Continuous
A comprehensive critical care solution beyond walls

17. Remote Monitoring SolutionsRemote Monitoring SolutionsRemote Monitoring SolutionsRemote Monitoring Solutions
• Providing remote ICU Management Services
to Hospitals in the US
• Acute shortage of intensivist in US
• Urban & Semiurban Hospitals, Rural Centers,
Government facilities do not have uniform technology
– which necessitates customization of solution
• Cost effective solution
Powering Critical Care

18. INTELEICUINTELEICUINTELEICUINTELEICU
• Specialist driven critical care beyond walls
• Access to services 24 X 7 (Critical Care – Anywhere, Anytime)
• Specialist driven critical care beyond walls
• Access to services 24 X 7 (Critical Care – Anywhere, Anytime)
Parameter ICUs in US ICUs in India
Extent of technological
penetration
Very high level Low to Medium levels
Definition of tasks, roles and
responsibilities
Well defined & documented Not as defined as in the US
Extent of human interface
for Tele ICU Management
Less; thanks to live feeds of
medical data from bed side of
patient
Very high; Significant paper data
Need / Problem Areas
Increasing need for 24 X 7
support to establish best
practices round the clock
ICUs in Metros – Value added
Service
For ICUs in non-metro areas & those
in Metros without round the clock
trained intensivists Required service

19. TYPICAL TELEMEDICINE SYSTEM

20. TELEICU MODEL