Emergency Care in India – Beyond 75 Years of Independence

Emergency care is being plagued by many gaps in the country

Advt.

Prof. (Dr) Tamorish Kole

Immediate Past President – Asian Society for Emergency Medicine (ASEM).
Past President – Society for Emergency Medicine, India (SEMI).
Visiting Professor – University of South Wales (UK).

India will be celebrating 75th Anniversary of Independence on 15th August 2022. Over the last 75 years, India has focussed on its scientific progress including healthcare; leading to Ayushman Bharat, World’s most ambitious national program for universal health coverage.

The Sustainable Development Goals (SDGs) reaffirm a global commitment to achieve universal health coverage (UHC) by 2030. This means that all people and communities, everywhere in the world, should have access to the high-quality health services they need – promotive, preventive, curative, rehabilitative, or palliative – without facing financial hardship. A strong Universal Health Care stands on three pillars

  • Primary Care
  • Emergency Care
  • Definitive Care (Secondary and Tertiary Level Care)

Need for Emergency Care

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, training and capacity building better outcomes and better cost-effectiveness can be achieved at same cost.

On May 30, 2019 Delegates to the 72nd World Health Assembly have adopted a resolution on emergency and trauma care aimed at helping countries to ensure timely care for the acutely ill and injured. It is estimated that more than half of deaths in low- and middle-income countries result from conditions that could be treated with prehospital and emergency care, including injuries; infections; acute exacerbations of cancer, diabetes and other noncommunicable diseases; and complications of pregnancy. In fact, WHO Director General Dr Tedros Adhanom Ghebreyesus emphasized that “No one should die for the lack of access to emergency care, an essential part of universal health coverage. We have simple, affordable and proven interventions that save lives. All people around the world should have access to the timely, lifesaving care they deserve.”

Well-organized emergency care is a key mechanism for achieving a range of Sustainable Development Goal targets, including those on universal health coverage, road safety, maternal and child health, noncommunicable diseases, infectious diseases, disasters and violence. It also helps WHO to fulfill the mandate of its Thirteenth General Programme of Work 2019-2023 to strengthen health systems, widen coverage of essential health services and improve integrated service delivery. India is signatory to this resolution and is a committed nation towards achieving this target. However, a population of 1.3 billion, high trauma death rate, increasing burden of emergencies and frequent natural disasters pose challenge to build an emergency care system for all citizens and in all parts of countries. According to World Bank, India, home to just 10% of the world’s registered vehicles, accounts for 22% of traffic deaths. Despite Covid restrictions more than 1.31 lakh people were killed due to road accidents in 2020. Road accident deaths increased by 7% in first 5 months of 2022, pointing towards immediate need to strengthen post-crash (medical) care.

Current Status of Emergency Care in India

On Dec 10, 2021; NITI Aayog, the apex public policy think-tank of the Government of India released two comprehensive reports on current status on Country level- secondary a& tertiary level and district level emergency & injury care in India. These reports highlighted the spectrum and load of emergency cases, prevailing gaps in ambulance services, health infrastructure, human resources and equipment in the provision of optimal care. As per this report, most of the hospitals lacked presence of general doctors, specialists and nursing staff dedicated for emergency departments vis-a-vis the average footfall of patients, even though the hospitals as such, had sufficient overall numbers of required human resource. This is a not a new finding but a reminder to decades of challenges and opportunities that is fundamental to our constitutional right to LIFE. (Article 21: “Protection of Life and Personal Liberty: No person shall be deprived of his life or personal liberty except according to procedure established by law.”)

Salient findings of the study are:

Private Vs Government Hospitals

  • Private Hospitals fared better than the Government Hospitals in terms of having emergency operative services, mock drills, training programmes, regular audits and referral policies.
  • Private Hospitals also ensure effective communication skills amongst care givers and timely delivery of care, translating into higher patient satisfaction levels.

Presence of ongoing academic program in Emergency Medicine

  • Hospitals conducting structured academic programs in the subject of Emergency Medicine have comprehensive robust systems in place for efficient patient care services including critical care and definitive care, tackling imminent disasters and continuous quality improvement.
  • These systems also ensure effective communication skills amongst care givers and timely delivery of care, translating into higher patient satisfaction levels.

Immediate Needs

Problem 1: CODE RED for Emergency Care – ED Overcrowding

Globally, Emergency departments, which were originally designed to provide immediate care for patients with time-sensitive conditions, are always under stress. Patients often go the ED when they cannot get care elsewhere. Health systems often send patients to the ED when they cannot accommodate them elsewhere. The ED was not designed for these uses, and they stretch its capacity, staffing, and resources, especially when it must also act as surge capacity for natural disasters, public health crises, and pandemics. This is a ‘CODE RED” for emergency care.

Solution 1: Manage Inpatient Beds effectively

The single most important factor affecting ED overcrowding is the availability of sufficient inpatient beds. ED overcrowding is best seen as a marker of whole-of-hospital dysfunction that requires a whole-of-hospital or whole-of-system response. Bed availability depends not only on the physical number of beds, but also on the way the bedstock is managed (appropriate use, good flow practices), competing uses for beds (eg, elective versus acute care), the availability of step-down units, and appropriate community care. In a nutshell, overcrowding is hospital / health system issue and not just a ED issue. Leadership must ensure effective in-patient management, more so with help of newer technologies.

Problem 2: Crisis and Catastrophe – ED Overcrowding

India has also witnessed catastrophic disasters in Uttarakhand, Assam, Himachal Pradesh, Jammu & Kashmir, Tamilnadu and many parts of the country. These incidents have been a stark reminder of the ability of disasters to overwhelm even the most advanced health systems and impact resource allocation. All of these incidents—earthquakes, a tsunami, a powerful Cyclone, Urban Floods, Hospital Fire—were sudden and unexpected, and all resulted in a disruption of infrastructure, including extreme stress and strain on health care systems. The need to allocate scarce resources during a catastrophic disaster is not unique to no-notice natural disasters; such circumstances may also arise in the aftermath of a catastrophic terrorist incident, particularly one due to the release of a bioagent or the detonation of a nuclear device, or a slow-onset event such as Covid pandemic. Emergency Departments (ED) are particularly vulnerable to overcrowding in disasters or even in day-to-day situations because of demand supply mismatch of healthcare resources in India.

Solution 2: Adopt of Crisis Standard of Care (CSC)

Adoption of Crisis Standard of Care (CSC). CSC is defined as a substantial change in usual healthcare operations and the level of care, which is made necessary by a pervasive (e.g., pandemic like COVID) or catastrophic (e.g., earthquake, hurricane) disaster. The continuum of care between the routine situation and disasters must be understood and accepted by all stakeholders related to Emergency Care.

Problem 3: Ever-growing Staffing and Deployment Crisis

Currently, due to increased demand, massive expansion of Emergency services and glaring skill gap, there are staff shortage both in side and outside hospital to provide effective care. Add to that, violence on ED staff, paramedics and stress due to systemic burn out. According to an Indian study, even verbal abuse in the workplace was personally experienced by 70% Indian respondents.

There is also a recent trend, of HR budget cuts among hospitals, towards emergency medicine. This has resulted in deployment of junior level staff in place of seniors, widening skill gaps, increasing level of stress and more attrition.

Solution 3: Roadmap for Upskilling

Firstly, we must address the skill gap and there is no quick fix for the same. While our, own educational pathways for emergency medicine are established now, it is obvious it will take years to match the demand. In the interim, we have to establish capacity building measures in PHYGITAL mode. This was tested and proven very useful during covid pandemic.

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