1 Critical Care: Career Options & OpportunitiesDr. Lava N Joshi MD ( Cardiology ) Consultant Cardiologist Om Hospital and Research Center

2 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.

3 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.

4 Following the Polio epidemic in 1952, DrFollowing 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.

5 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.

6 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.

7 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.

8 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.

9 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 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

10 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

11 Considering population of around 20 million in 2011, there are only 15Considering 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.

12 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.

13 ICU AUDIT Magh 1st 2070 - Jestha 2072

14 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

15 “Age Distribution” This Graph represents the division of the patients admitted according to their age group. The maximum number of patients fall under the age group 70+. Chronic debilitating conditions such as COPD, Malignancy, Chronic liver disease, Cerebro vascular accidents are the most common presentation in this group. Another notable age group is 21-30: Alcohol related diseases and poisoning cases are the commonest in this age group. Patients in the age group 1 to 10 are rarely admitted in our ICU as our centre is considered as a centre for adult patients only.

16 “Systemic Disease Categorization”This Graph shows the distribution of admissions of patients according to various systems/ departments involved. Respiratory cases such as chronic obstructive pulmonary disease, asthma, pneumonia and pulmonary TB are the commonest. The total of 367 patients have been admitted during this period with respiratory problems. Endocrine cases such as DM and Pancreatitis are the common ones in our ICU. Nephrology cases such as Chronic kidney disease were abundant in the primary phase but reduced along the course of time due to absence of Hemodialysis and burden in transferring the patients into other centers just for dialysis purpose

17 “Duration of stay” Usually the admitted patients in the ICU stay for a duration of 1 to 3 days followed by 4 to 6 days % of total admission stayed in the ICU for 1 to 3days Rarely patients are admitted for more than 10 days

18 “Ventilator Used” This graph shows the total patient kept under ventilation and their outcome. A total of 222 patients have been kept under ventilation and 128 were successfully extubated where as 94 patients deceased. Since Magh 2070, 42% of the total patients kept under ventilation have expired till Jestha 2072. The maximum patients who expired under ventilator support were cancer chemotherapy cases and patients on palliative care and patient who were extubated on patient parties request.

19 Global challenges Critical care is costlyWith increase in life expectancy and improved overall care of patients, the need for ICU bed is increasing

20 Crit Care Med 2010;38:65-71

21 The key challenge for the future will be to provide adequately trained intensivists as there is a predicted shortfall. Crit Care Med 2008;36:

22 Training programs in NepalDM program in Critical Care Medicine started at Institute of Medicine, Tribhuvan University from October 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)

23 Introduced in BPKIHS Dharan in 2014DM Pulmonary Critical Care and Sleep medicine, started in Bir Hospital NAMS in 2012 Introduced in BPKIHS Dharan in 2014 JSAN 2014;1(2)

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25 Levels of ICU Level III: Tertiary referral unitShould 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

26 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

27 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)

28 Defined protocols, admission, discharge and referral policiesSuitable infection control and isolation procedures and facilities 24 hours access to pharmacy, pathology, operating theatres and imaging services

29 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

30 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

31 Run by medical director – full time commitment to the operation of ICU and trained in Intensive Care Medicine Nursing requirement similar to Level III

32 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

33 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

34 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.

35 THANK YOU ALL FOR YOUR KIND ATTENTION.