NEW DELHI: In a first, the government has come up with “Guidelines for Intensive Care Unit Admission and Discharge Criteria” 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 of 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 that have already been put in public domain by the Directorate General of Health Services (DGHS), the apex technical advisory and regulatory body of healthcare under the health ministry, may help adjudicate better whether ICU admission was a requirement in certain cases.
The guidelines suggest that a patient should be discharged from ICU, if her/his physiological aberrations return to near normal or baseline status or if there is reasonable resolution and stability of the acute illness that necessitated ICU admission. Discharge is also suggested if the patient/family agrees for ICU discharge for a treatment-limiting decision or palliative care.
As for manpower, the guidelines mandate the availability of intensivists or critical care specialists – specialists with specific training, certification and experience in managing critically ill patients in ICU. Alternatively, they suggests MBBS graduates with extensive experience in intensive care, quantified as at least three years’ experience in ICU (at least 50% time spent in ICU).
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