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.

Some thoughts on turning around of RSBY in West Bengal

Some thoughts on Turning around of Rashtriya Swasthya Bima Yojana (RSBY) in West Bengal

 

1.     Introduction

Implementation of RSBY was shifted from Director ESI under Labour Department to Health & Family Welfare Department of West Bengal Government on 23^rd September 2013. The scheme is sponsored by Ministry of Labour & employment Government of India and State Budget in 75:25 sharing pattern for payment of premium. BPL and MGNREGA beneficiaries in all districts of West Bengal including Kolkata are covered under the scheme which assures cashless free treatment up to Rs 30000 per family in any of the enlisted 726 hospitals throughout West Bengal for the family of 5 members enrolled. Biometric smart card containing 64 Kb chips are used just like ATM cards to access the indoor services in the enrolled hospitals which are connected to online network and operates on common Transaction Software.

1.1 There were 56 lakhs families enrolled under the scheme in September 2013 insured under RSBY in 18 districts excluding Kolkata. Annual rates of premium were Rs 459 per family per annum in most of the districts and Rs 430 in few districts.

1.2 Free indoor treatment services were being provided through the network of 521 hospitals including 20 Government hospitals enlisted with the scheme. 97000 patients accessed free indoor treatment, mainly surgical interventions from March to September 2013, with monthly average of 14000 patients.

1.3 RSBY health insurance policy is renewed after 12 months at the same rates on three year rate agreement with the Insurance Companies subject to fulfilment of performance clauses of the agreement.

1.4 At district level one ADM in the District Administration implements the scheme assisted by Third Party Administrators (TPA) appointed by Insurance Companies and District Grievance Redressal Committee (DGRC) acts as arbitrator and authority to resolve public grievances. Enrolment of families and issue of RSBY smart cards online is done by the Field Key Officer (FKO) appointed by ADM through IT based network connected system having proper authentication. This is one of the best delivered services in public sector with strong IT plate form.

1.5 TPAs conduct medical audits of treated patients and action of de-empanelment of hospitals and new enlistment is done by them as per agreements. 

2.     Major initiatives and interventions in last one year to strengthen RSBY in West Bengal  

2.1 State Nodal Authority of RSBY set up wef 23^rd September 2013. In addition to erstwhile team of SNA transferred from ESI Directorate, dedicated medical audit teams under the Technical Officer (Senior West Bengal Health Service Cadre medical officer) were notified. There is Medical Audit team in each district headed by Dy CMOH-1 and comprises of specialists from surgery, gynaecology, orthopaedic and eye surgeon from the Government hospitals. System of medical audit by TPAs strengthened and accountability of health care providers improved.

2.2 Package rates of treatment were revised adding new packages for indoor as well as day care treatment. Now, there are more than 1460 packages of surgical and general medicine treatment compared to 1200 last year. Rates of all the packages have been revised and technical changes were made in the packages as per the current rates and treatment guidelines. Expert Committee comprising of Medical College Professors and Specialists examined all the packages and their recommendations accepted by the SNA and Insurance Companies. Now, the rates and packages are uniformly followed in all 726 hospitals in the State wef 1^st April 2014. These packages are lucrative to health care providers and cover all the treatment costs, thereby reducing out of pocket expenses. For example, General Medicine admission charges increased from Rs 500 per day to Rs 750 per day. Similarly, charges of ICU increased from Rs 1000 per day to Rs 1500. Most of the packages have been revised upwards. Number of cases of refusal to admission by hospitals decreased substantially and rate of hospitalisation has increased thereby ensuring access to card holders.

2.3 In terms of the Policy of the health & family welfare department, Government Hospitals from Medical College Hospitals to State General Hospitals were compulsorily enlisted under RSBY as health care providers. There are 104 Government hospitals under RSBY now and numbers of private hospitals have increased from 501 to 602 in last one year. RSBY helpdesk comprising of minimum 5 Rogi Sahayaks in secondary hospitals and 8 in Tertiary care hospitals have been supported from RSBY fund in Government hospitals facilitating admission & treatment of RSBY card holders. There has been sharp increase in treatment claims in Government Hospitals from merely Rs 1.8 Crores last year to Rs 14 Crores this year. Government hospitals have been allowed to retain this income from RSBY and utilise for the benefit of patient services in hospitals.

2.4 Rs 100 per patient each admission and maximum of Rs 1000 per annum is paid for transport allowance under the scheme. Extra Rs 200 per patient and maximum of Rs 2000 per annum has been allowed by SNA in Government hospitals wef 1^st April 2014.

2.5 DGRC were activated and District Level Implementation Committees were constituted for better service delivery and ownership of the scheme. Workshops at each district with block and municipal level functionaries, health care providers and TPAs were organised twice in the year. Regional workshops with hospitals were organised facilitating claim settlement and grievance Redressal thereby improving the hospitalisation. Fortnightly review meetings at SNA with Insurance Companies and TPAs have been effective in monitoring Programme Outcome.

2.6 Fresh competitive biddings were conducted in 11 districts last year for selection of Insurance Companies. Premium rates came down to Rs 185 to Rs 245 per family per annum. This provided annual savings of Rs 103 Crores each year due to low premium rates. This is in addition to increase in free treatment reimbursement due to better access and revision of packages. Enrolment of families completed in record three months from January to March 2014. RSBY cards with female as head of family were issued for the first time in any State in the country. West Bengal has 60.16 lakhs live smart cards as on date. This is the highest number of cards in any state in the country.

3.     Achievements and outcomes 

3.1 These interventions have contributed in improving the access and outcome of the RSBY programme in West Bengal in last one year. Enrolment increased by four lakhs and number of lives insured increased by 23 lakhs. There are 209 lakhs persons insured under RSBY in West Bengal.

3.2 Total 3.10 lakhs patients availed free indoor treatment in enlisted hospitals in last one year. Claims of treatment of Rs 210 Crores were generated during the period. There has been increase in rate of hospitalisation per month and substantial decrease in rates of premium.

3.3 Network of enlisted hospitals widened and introduction of Government Hospitals improved access to quality health care. This has also benefitted these hospitals by ensuring sustained revenue for maintenance of patient services. It is projected that at least Rs 20 Crores will be generated by Government hospitals in the current year which will help them financially. Helpdesk in all hospitals will directly helps then patient in these hospitals.

3.4 Projections on outcome and financial benefits are depicted in the table below :- 

Trends of Patient hospitalisation and benefits under RSBY in West Bengal in 2014-15
Number of Patients hospitalised and got free indoor treatment from Feb to April 2014	64850
Total Premium liability to be paid (in Rs lakhs)	4590
Per month Premium in Rs lakhs	2295
Total value of free treatment in Rs lakhs	3674
Per month benefits (in Rs lakhs)	1837
Net savings per month in Rs lakhs	-458
Total savings in Rs lakhs	-916
Number of Patients hospitalised and got free indoor treatment from April to August 2014	147150
Total Premium liability to be paid (in Rs lakhs)	5400
Per month Premium in Rs lakhs	1080
Total value of free treatment in Rs lakhs	9726
Per month benefits (in Rs lakhs)	1945.2
Net savings per month in Rs lakhs from April to August 2014	865.2
Total savings in Rs lakhs from April to August 2014	4326
Annual savings projected at current trends in Rs lakhs	10382.4
Annual Premium liability projected in Rs lakhs	12960
Annual free treatment projected at current trend in Rs lakhs	23342
Current trend of free indoor treatment per month in numbers	29430
Annual free indoor treatment projected at current trend in numbers	353160
Net annual free treatment cost with 94 % claim settlement in Rs lakhs	21942
Net annual savings to the State in current year with these projections in Rs lakhs	8982

 Conclusion:

RSBY performance has substantially improved in last one year in West Bengal, which has been appreciated by MoLE. Improvement in quality of outcome, reduction of cost of services and net benefits to the BPL and MGNREGA families under RSBY is West Bengal can be easily understood from the facts depicted herein. There is lot of scope to take it forward and improve the outcomes.