GS Paper II

News Excerpt:

Union Ministry of Health and Family Welfare has released the first-ever Intensive Care Unit (ICU) admission and discharge guidelines.

Key highlights of the guidelines:

• The guidelines have been developed by a panel of 24 eminent physicians, which includes experts from Dubai and Canada, these guidelines set clear criteria for ICU admissions and discharge.
• Nature of Guidelines:

• • The guidelines are only advisory in nature and are not binding on hospitals or doctors.

• Intensivist or Critical Care Specialist:

• • These have been categorised as specialists with specific training, certification, and experience in managing critically ill patients in an ICU.
  • But if doctors do not have the requisite qualifications or training, those with extensive experience in intensive care in India after MBBS — quantified as at least three years’ experience in ICU — can also work as an ICU doctor.

• Monitoring Criteria:

• Parameters such as blood pressure, pulse rate, respiratory rate, breathing pattern, heart rate, oxygen saturation, urine output, and neurological status are highlighted as critical indicators that should be continuously monitored for patients awaiting an ICU bed.

• Admission Criteria:

• • Inclusion list:

• Patients with an altered level of consciousness or with a recent onset hemodynamic instability — such as shock and irregular heartbeat.
• Patients with acute illness requiring intensive monitoring or organ support should be given ICU care.
• Patients with medical conditions or diseases anticipating deterioration, those who have experienced any major intraoperative complication, and those who have undergone a major surgery should be admitted.

• • Exclusion list:

• • • • Hospitals cannot admit critically ill patients to the intensive care unit if they and their relatives refuse to do so.
      • Those with low-priority criteria in a pandemic or disaster situation with resource limitations should not be admitted to ICU.
      • Critically ill patients should not be admitted to ICU if any disease has a treatment limitation plan.
      • Anyone with a living will, or advanced directive against ICU care and also terminally ill patients with a medical judgment of futility should not be admitted to the ICU. A living will is a legal document detailing the type and level of medical care a patient wants to receive if they are unable to make decisions or communicate their wishes when care is needed.

• Discharge Criteria:

• The return of physiological aberrations to near normal or baseline status, reasonable resolution and stability of the acute illness that necessitated ICU admission, and patient/family agreeing for ICU discharge for a treatment-limiting decision or palliative care.

Need for the guidelines:

• The ICU care, in several cases, imposed unjustifiable emotional and financial burdens on families of patients who are terminally ill or in the last stages of an incurable illness.
• Experiences during the pandemic showed that there was a huge shortage of ICU bed facilities.
• In the era of increasing penetration of health insurance, problems related to third-party payment and medical litigations are frequent.
• ICU care is a valuable, expensive, and scarce resource. So, it must be used with due care.
• Without best practice guidelines, utilisation of the ICU is arbitrary and subject to misuse.

Significance of guidelines:

• India is a diverse country, and ICU care facilities are not uniform across Tier 1, 2 and 3 cities and in remote places.
• Hence, these guidelines may help define who can be termed an intensivist and their responsibilities, apart from the broad criteria for admission and discharge in the ICU.
• Since ICU beds may be filled with those who are for terminal care, many patients with curable ailments may be denied life-saving care.
• Following the latest advisory will prevent such a scenario.
• These guidelines provide a direction as to which critical patient requires ICU care.
• The guidelines emphasise the importance of obtaining prior consent from patients or their relatives before admitting critically ill individuals to the ICU.

Conclusion:

The rationale behind the guidelines is to streamline the admission and discharge process in the ICU. These guidelines provide a simple, practical, and actionable path across the country and give clinicians, patients, and their caregivers sufficient autonomy to make informed decisions. To avoid burdening existing ICU facilities, there is a need to follow certain guidelines like avoiding end-stage or terminally ill patients and offering them good quality palliative care at high dependency or in palliative care wards.