Meeting of RSBY with ADMs on 27th August 2014

Critical Care and Emergency facilities in secondary hospitals - unique approach in West Bengal

1. Introduction

Critical illness therapeutic and life support care management in developing countries is becoming popular in last decade but most of these facilities are in Private Sector except teaching Government hospitals and select district hospitals. In Indian context, very few hospitals at district level or below 300 bed capacity has Intensive Care Units and Therapeutic Care units. Wherever such facilities has come up at secondary hospitals these are having only 4 to 6 beds. There are numerous ICUs/ ITUs and Critical Care units,  as sometimes these are called, in Private Nursing Home or hospitals in all states. Some of the challenges in critical care access are as noted below :-

• Number of Critical Care ICU beds are highly inadequate compared to need for critical illness arising out of vector borne diseases, trauma, accident cases, cardiac and respiratory critical illness and other critical conditions.
• Not fully equipped to provide resuscitation,  ventilation, dialysis, life support systems.
• Inadequate and under trained medical and support manpower in availability as well as 24X7 presence.
• Very high cost of care which leads to catastrophic effect. In some cases patient party is forced to discontinue critical care support due to non affordability of the treatment cost.
• Emergency transport equipped with advanced life support is always not available thereby resulting in loss of time during golden hours.

In order to achieve the objectives of vision of accessibility to affordable, quality, sustainabed health care in the State, the Department of Health & Family planned unique approarch of setting up Critical Care Units and High Dependency Units at Secondary Hospitals with the target of the facility within 50 Kms from any habitation in the state. West Bengal, is the probably only State to have planned and put this plan in reality in a year for Critical Care facility in Government hospitals at Sub divisional and State General/ Rural hospitals. Details are highlighted in this write up.

2. Background

Under the guidance of Hon’ble CM West Bengal & MIC, the Health & Family Department Constituted 13 member Multi Disciplinary Expert Group (MDEG) under the Chairmanship of renowned Critical Care Expert Dr Subrata Maitra in March 2013, inter alia to study the functioning of Public Hospitals under the administrative control of this department and provide technical support for improvement and up gradation of health care services at secondary and tertiary care hospitals. The MDEG conducted intensive study of all Government run hospitals at Sub divisions, districts and medical college hospitals during their field visits, interacted with the doctors, nursing personnel, support staff, patients and people from wide spectrum of the society during last one year and submitted detailed recommendations to the State Government on improvement of health care services. One of the recommendations of the MDEG was to introduce the Emergency and Critical Care at secondary and tertiary hospitals of State Government in phased manner so as to ensure affordable, efficient and reliable Critical Care access to all within 50 kilometers radius from the habitation throughout the State of West Bengal.

3. What are CCU/ HDU?

CCU comprises of Intensive Care Units or Intensive Therapy Units with sophisticated equipments and set down beds. These units were decided to be set up near emergency and will be equipped with sophisticated equipments as per the advice of the experts installed in the same premises with 24X7 Critical Care Support, hospital services, emergency referral system, imaging, pharmacy and pathology. Equipments like ventilators, pulse oxymeters, multi channel monitors, rapid infusion pump, blood gas & electrolyte analyzer, Biphasic External Defibrillator, Microbial Culture Machine and fogger machine etc will be installed to ensure all critical care support for emergency, accident cases and cardiac patients at decentralized hospitals.

There are dedicated manpower of Medical Officers, Nursing personnel, Critical Care Technician, GDA and Sweepers to run these units 24X7. All the manpower has been imparted minimum 6 to 8 weeks Critical Care hands on training under the guidance of Critical Care Experts and Professors before their deployment in these units.

4. Progress of CCUs/ HDUs in West Bengal

Based on mapping of the facilities 70 CCUs/ HDUs were planned out of which six were commissioned and made functional by July 2013  and 24 CCUs and 8 HDUs during September  2013 to June 2015. At present 30 CCUs and 8 HDUs are functional. Two more CCUs and 4 HDUs are being inaugurated on 14th August 2015.

In summary there are 41 CCUs planned with 12 beds each at district and sub divisional hospitals (11 in Teaching hospitals with 24 beds each) and 27 HDUs with six beds at State General Hospitals and SD Hospitals. All these facilities are likely to be functional by end of 2015.

State Government has so far approved setting up 70 Critical Care and High Dependency Units in all Secondary & Tertiary hospitals of West Bengal to provide Critical & Emergency Care to patients at secondary hospitals. Proposal for the sanction of creation of 2408 regular posts of medical, nursing, technical and support staff in the hospitals has also bee approved. 28 HDUs with six beds each have been approved at SGH or RH level. In addition 102 emergency observation wards of 4 to 8 beds have been set up in Secondary hospitals.

5. Civil and Electrical works for site preparation

It was planned to upgrade the existing hospital buildings of hospitals vertically or horizontally to prepare the sites for setting up of the units in these hospitals, for which capital expenditure was incurred for civil and electrical works. Unit cost of Non-recurring expenditure is Rs 290 lakhs, Rs 260 lakhs and Rs 140 lakhs for 24 bedded each in Tertiary Hospitals (8 beds Intensive Care Unit and 16 beds High Dependency Unit), CCUs of 12 beds (4 beds ICU and 8 beds HDU) each in Secondary Hospitals with more than 300 indoor beds and 27 HDUs of 6 beds each with up to 300 indoor beds hospitals respectively.

Conclusion :36 units are functional and 6 more units to be opened next month. More than 8000 patients in critical conditions managed by these units in last six months.

The fact that critical care treatment in these Government facilities is free or at very nominal rates for those who can afford, makes the initiative most successful. Out of pocket expenditure of patients will decrease substantially.

These hospitals are enlisted under RSBY and earning revenue out of RSBY which have been allowed to be retained by them to take care of any short fall in running expenditure of these facilities.

This unique approach takes care of most of the challenges of Critical Care as highlighted in the introduction paragraph.

One successful year of Online Clinical Establishment Licenses of Private hospitals and nursing homes in West Bengal

Updates on 29th July 2015 : Online application and uploading  of supporting documents was started in Kolkata District initially from August 2015 which was scaled up to all districts of West Bengal from 1st December 2014, discontinued old practice of manual application in CMOH offices. In 8 months, 750 Clinical Establishment Licenses were issued online in transparent process. Details on equipments,  manpower and services of hospitals are available on Health Department server. We can monitor and track application for any district and ensure timely disposals. We hope all clinic establishments uses this facility. Steps are being taken to make it more user friendly . System is linked to SMS gateway and being linked to SMTP gateway shortly when real time  communication on shortcomings in application and findings of inquiry cam be shared with applicant. Scrutiny  sheets are still accessible by applicants through user login. 


 Introduction

 terms of Clinical Establishment Act all the hospitals,  nursing homes and day care centres are required to get CE License from the licensing authority to run the establishment.  CMOH in districts and Deputy Director Health Services Administration in Kolkata are the licensing authorities to issue new license or renew the existing license.

Application is required to be filed with plan of hospital, clearances from fire safety, building plan, Pollution control,  Bio Medical Waste disposal, manpower details and requisite fees in the office of licensing authority. License is issued within 60 days after conducting enquiry by ACMOH or similar rank officers after physical inspection of the establishment and checking inter alia equipments and manpower availability.

2. Online Web Based Application Software introdcued from 1st August 2014 for Kolkata

Web based application software has been introduced from 1st August 2014 for Kolkata district initially. Applicant can fill the online application on available at www.wbhealth.gov.in on link Clinical Establishment and can also upload documents as attachment. Fee can be paid in SBI through treasury challan and printed copy of filled in application along with affidavit in original and challan of fee in original can be delivered to licensing authority.

• Date of inspection is assigned in the system which is notified to applicant instantly.
• Similarly,  remarks of enquiry officers are also fed online and known to applicant instantly which he can comply.
• Once the enquiry reports are uploaded CE License can be printed and delivered.
• In case of any adverse reports or shortcomings in application the same can be known from the server on email.
• The software has fixed time limits determined by system for enquiry and issue of license.  So it ensures service delivery in time.  Date of submission of original challan of fees and affidavit is the date of application.
• Enquiry or inspection where applicable is mandated to be started in 15 days of receipt of application and to be completed by 55th day of application.
• The CE License to be issued through the web application software within 60th day of filing application except the unavoidable circumstances for which reasons to be recorded in writing and intimated to the applicant.
• Applicant is informed at every stage online so that he can rectify defects in application.

Good response received so far in last three weeks. Bulk sms to all licensees is planned in addition to newspaper ads to appraise them about new system already notified by the State. Once all the details are filled for the first time,  renewal application will be very easy.

3. Future plans

Apart from extending the system to all districts in the current financial year, online reporting of compulsory reports from the private hospitals and nursing homes like public health prorammes, vital statistics, emergency disesses and periodical reports can be done. At present these reports are submitted manually on weekly and monthly basis.