Govt hospitals: Ails and cures

CHENNAI: Nothing justifies the lackadaisical attitude of doctors in the post-operative care of footballer Priya who died recently. Taking accountability would not compensate for her loved one’s loss, but an analysis of the public healthcare system can prevent such incidents from recurring.

The shoddy after-care meted out to Priya pointed out to several glaring lapses in the healthcare set up. Issues such as lack of advanced equipment, no system of checklist or treatment protocol, inadequate manpower, lack of automation, heavy workload in the public health sector including that of doctors and medical personnel, lack of maintenance of facilities, etc have been raised by the medical fraternity. And the list goes on.

While the doctors’ fraternity at large feels unjustly attacked as they’re blamed for every lapse in the healthcare sector, they also insist that negligence was, and would never be, intentional. They urge the government to take steps to ensure quality treatment in government hospitals with relevant improvements made in the public health sector.

No modern tech

Diagnostic exam is the first step towards effective medical care, closely followed by timely treatment with minimal risk and complications, making the prognosis more favourable.

And a prerequisite for correct diagnosis is reliable diagnostic and lab equipment. Modern medical devices equip the healthcare sector with tools to perform their functions efficiently.

Doctors in government hospitals (GH) lament that lack of modern equipment prevents them from performing emergency services such as a caesarean delivery, as it requires facilities such as a blood bank, ambulance, operating theatres, obstetricians, paediatricians, and anaesthesiologists.

“Without one of them, the case can turn critical. Some of the equipment used in private hospitals are not costly and even that’s not available in the government sector,” says a government doctor from the Institute of Obstetrics and Gynaecology. “For instance, we don’t have machines to do a CT and/or MRI scan here. So, patients go to the Institute of Child Health or Rajiv Gandhi Government General Hospital for that. It’s not an X-ray that’s required nowadays; doctors prefer precision for quality treatment and these are just the basics.”

Poor infrastructure

Lack of adequate systems and infrastructure contributes to hospital-associated infection. Prevention and control of infections take a back seat in many GHs and primary healthcare centres (PHC). The common advances made in different specialities of medicine in private health sector ensure quality healthcare, even if it’s expensive.

“Arthroscopy is a procedure for diagnosing and treating joint problems. Through a small incision (the size of a buttonhole), a surgeon inserts a narrow tube that has a fibre optic video camera in it. For this procedure, there’s a feature that automatically deflates the compression bandage after surgery. But in the GHs, we do not have that,” explains Dr GR Ravindranath, secretary of Doctors’ Association for Social Equality.

Due to high cost of treatment in the private sector, most people from the middle-class and below visit GHs. Considering a large section of the population in India, and Tamil Nadu in particular, is from that segment, it’s prudent to strengthen GHs and PHCs with advanced equipment, technology and infrastructure.

“The proton therapy is a good treatment option for cancer care, but even that’s not available in the public sector. And in private hospitals, it’s out of reach for the common man,” rues Dr Ravindranath.

He added that lack of facilities delays treatment, and the fallout is ultimately taken by the treating physician and/or surgeon. “Doctors feel handicapped without basic equipment. And equipment providers should also more invested, in the sense that their responsibility does not end with sales, supply and installation but also maintenance. But such concerns and grievances can be conveyed only if periodic meetings are held between medical professionals including doctors, nurses and other healthcare staff, and the powers-that-be, which is a rarity in public health sector,” explains Ravindranth.

Lack of automation

From simple forms, medical history of a patient and internal policies to details of surgical procedures, doctor visits, medications given, post-operative care if any and more, document management and healthcare go hand in hand. In fact, it would be nearly impossible to properly care for patients and care for a surgical patient without managing medical documents.

That’s a huge responsibility and it inevitably falls on duty nurses, who have to spend a lot of time doing non-medical tasks such as clerical work, documentation work or insurance-related work. It leaves them with less energy and time to spend on patient care.

Around 2 years, the State Health Department had promised the implementation of digitisation of medical records in GHs across the State. That’s yet to take shape.

If there was a system of one unique ID for a patient, it’d be helpful to get their medical history. This can help with quicker diagnostic testing and treatment.

“The system should also be reformed through digitisation and automation so that an individual patient ID is adequate to understand their medical history. This also helps doctors to update the existing treatment, if need be, and decide on further course of action for the patient,” avers emergency physician Dr A Hakkim. “In certain emergency cases, we work on a blank slate – we don’t know their medical history or if they have any drug allergies or the treatment they’re currently undergoing. This can delay our diagnosis and cause complications.”

Paperless procedures can reduce the chances of man-made errors and become a game changer especially in trauma cases.

Workforce vs workload

Public healthcare experts say that the concerns of infrastructure and workforce leads to unfortunate incidents and the root cause needs to be identified and resolved. The number of nurses to patient ratio is disproportionate in GHs when compared to private hospitals.

“One pregnant mother requires one nurse to record parameters and monitor overall health. There are certain factors that need to be recorded every 30 minutes to an hour. However, in most GHs, one nurse is responsible for many patients who are in similar critical situation and require attention. This makes it difficult for nurses to exercise their duties,” says former Directorate of Public Health and Preventive Medicine, Dr K Kolandaisamy.

The GHs in the city do not have adequate nurses and the situation is even worse in the peripheral hospitals and PHCs.

“Doctor-nurse to patient ratio is poor, particularly in post-operative care, trauma and pregnancies,” he adds. “This leads to lack of attention to each patient and affects quality treatment.”

Nurses are burdened with a ton of paperwork — type of equipment used, tests ordered, medication administered, monitoring patient’s condition, maintaining charts, case sheets, follow-up details and others. They need to keep them up to date for doctors and/or surgeons to recommend course of treatment. But this documentation, done manually, is time-consuming which affects patient care at the hospital.

“Doctors rely on the information we provide about a patient. We have to monitor every IV, injection, medication and the overall health of the patient and inform the same to the chief doctor whenever the latter is on rounds,” describes a nurse of a typical day at Stanley Medical College and Hospital. “We document everything so that the doctor is aware of the patient’s current health condition and the treatment given in the ward. Then the doctor gives us instructions to be carried out for the patient.”

The number of nurses and healthcare staff in each ward is woefully inadequate. Dr Ravindranath says that it’s one of the reasons why postgraduate students are given continuous work from 24-36 hours to even 48 hours sometimes.

“Such a working condition causes physical and mental stress. Only 8-12 hours of work per day should be allocated. Weekly leave should be given as sanctioned by the university,” he points out.

Qualified support staff

The responsibility of post-operative care or other associated services fall on the nurses and support staff, but the accountability is low. Moreover, healthcare experts say that appointment of qualified staff is important than just filling in vacancies.

“Outsourcing of staff is another problem because it’s not easy to filter qualified staff. A skilled workforce is important, even for dressing a wound or taking care of a patient,” explains Dr Kolandaisamy. “We need to create awareness among healthcare workers and educate them on the impact of a particular health condition of a patient. Staff and nurses must be trained in taking accountability so that when a patient is in their care, any changes in health condition can be attended on an emergency basis.” says.

There are government courses and training sessions available in the State, but recruitment does not reflect them. “Instead of blaming it on someone and conducting an audit of an incident/surgery, it should be the underlying factors that need to be addressed,” he states.

WHO checklist

World Health Organisation had released a checklist on surgical safety and other standard operating procedures to ensure patient safety. The checklist, treatment guidelines, referral policy, pre- and post-operative care and follow-up training should be implemented in every hospital (both public and private) to prevent lapses in treatment.

“It’s a user-friendly checklist system, which was formulated after two years of research and includes inputs from doctors, nurses, surgeons and healthcare staff. It can vary for every procedure and can be changed accordingly for each procedure,” tells senior vascular surgeon Dr Amalorpavanathan Joseph.

If this checklist is followed in GHs and PHCs across the State, all procedures can be audited to identify and resolve issues.

“A checklist can be a comprehensive approach to any process in the field of medicine and can be used to prevent a good percentage of complications. As per the checklist, healthcare staff can be trained in many ways that equips them in handling complications, if any,” he adds. “Locally, we need to continuously review the operations at all GHs and also conduct self-audits to prevent similar lapses in ICUs, and especially in cases involving pregnancy, emergency and trauma.”

Referrals from private hospitals

Under emergency circumstances, people get admitted in any private hospitals. Later, due to a myriad of reasons (high cost of healthcare being the foremost), they decide to move to a GH.

But, by the time it happens, the patient’s health condition deteriorates, and often leads to a fatality that’s inevitably registered as mortality in GHs. That’s also one of the reasons why there’s high mortality rate recorded in GHs when compared to private hospitals.

“Private hospitals also make last minute referrals to GHs for various other reasons. One of the main issues is to avoid medico-legal problems that can arise due to medical complications. They’d also want to avoid conflict between the patient’s loved one and the medical staff,” describes Dr P Vasanthamani, former dean of Kilpauk Medical College and Hospital. “When they reach GHs at a severe stage, the death is registered here. Also, autopsies from private hospitals are not accepted as legal document.”

The number of nurses to patient ratio is disproportionate in GHs when compared to private hospitals, and the situation is worse in peripheral hospitals and PHCs