Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018).

BACKGROUND: A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels. AIM: To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions. METHODS: The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23rd-August 25th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status. RESULTS: There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability. CONCLUSION: In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analyis.

BACKGROUND: Improvements in intensive care in the last few decades have shifted the focus from mortality to quality of life of survivors as a more important outcome measure. Allocation of public resources towards intensive care is an important challenge for healthcare administrators. This challenge is made more arduous in resource limited countries like India. Thus, it is imperative to consider patient centerd outcomes and resource utilisation to guide allocation of funds. The aim of this study was to evaluate the quality of life of long-term survivors, and to perform cost-effectiveness and cost-utility analysis. METHODS: Data was retrieved from the records and included age, gender, admission diagnosis, length of ICU stay and mortality. Costing methodology used was top down approach. Quality of life was assessed by SF 36 scoring which was done with personal interview and telephonically. Cost-effectiveness analysis was done on the basis of years of life added. Cost utility was done by QALY gained. RESULTS: A total of 1232 adult patients were admitted in the period with 758 (61%) being successfully discharged from ICU with a mortality rate of 39%. Out of 758, we could contact 113 (15%) patients. 86 patients were alive at the time of contact who could fill the forms for quality of life. The patients discharged from ICU had scores almost similar to the general population. Lesser scores were noted in physical functioning and general health perceptions, though this difference was not statistically significant. The life years gained were significantly more in younger patients. The cost per life gained was more in patients aged more than 50 years compared to those who were younger. CONCLUSION: The quality of life after survival from ICU is as good as in the general population. The intensive care provided in our ICU is cost effective. HOW TO CITE THIS ARTICLE: Mishra SB, Poddar B et al, Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analysis. Indian J Crit Care Med 2019;23(3):122-126.

Trans-Esophageal Doppler Assessment of Acute Hemodynamic Changes Due to Prone Positioning in Acute Respiratory Distress Syndrome Patients.

BACKGROUND: Effect of prone positioning on acute hemodynamic changes (within 10 min) in acute respiratory distress syndrome (ARDS) has not been studied. METHODS: In this prospective observational study, hemodynamic assessment by trans-esophageal Doppler (TED) was done with the primary aim of measuring early changes in cardiac index (CI), if any, after prone positioning in moderate to severe ARDS patients. A subgroup analysis was also done based on the response to passive leg raise (PLR). RESULTS: The baseline hemodynamic variables of 26 included patients were: CI 3.5 (3.1-4.3) L/min/m, peak velocity (PV) 83.2 (60.9-99.3) cm/s, flow time corrected (FTc) 341 (283-377) ms, mean acceleration (MA) 9.0 (7.04-11.7) m/s. After prone position, there were no statistically significant changes in CI, 3.5 (P=0.83), 3.75 (P = 0.96), 3.7 (P = 0.34), and 3.9 (P = 0.95) at 5, 10, 20, and 30 min respectively. FTc, mainly indicator of preload, showed decreasing trend to 315 (275-367) ms at 30 min post prone (P = 0.06). On the basis of PLR test also, CI did not change significantly in both PLR+ and PLR- groups. In PLR+ group, PV increased from 72.4 to 83 (P = 0.01), 74.9 (P = 0.03), 82 (P = 0.02), and 82 (P = 0.03) cm/s; while in PLR- group, MA increased from 8.8 to 9.7 (P = 0.03), 10.1 (P = 0.03), 9.3 (P = 0.04), and 10.6 (P = 0.01) m/s at 5, 10, 20, and 30 min respectively. CONCLUSIONS: In moderate to severe ARDS patients, there were no significant changes in CI during first 30 min after prone positioning, even in the subgroups on the basis of PLR response.