Care of the critically ill patient is undeniably complex. Standardised protocols for critically ill patients represent a potential solution to this issue; here is a case study of Lucknow's KGMU  which has adopted diligent practises and safety protocols leading to patients' survival rate increasing from erstwhile 40 to 60%.
 

Owing to a number of factors such as interdependence of the practitioners, dependence on team functioning and the very basic nature of the complexity of the disease of the patient,  the intensive care unit of a health care system is believed to be an area with a high probability of medical errors.

Strict adherence to basic precautions and best practices in Intensive Care Units (ICUs) can drastically increase patients' chances of survival and Lucknow's King George's Medical University (KGMU) has demonstrated this over the past 11 months.By diligently practising the safety protocols followed in countries such as Australia, England, and the United States of America, the hospital's pulmonary and critical care department has witnessed patients' survival rate increasing from erstwhile 40 to 60%.

Fessler HE, Brower RG define protocols as 'sets of explicit, algorithmic rules, which direct clinical management or research' (Fessler HE, Brower RG. Crit Care Med 2005.). Checklists, however, only amount to list of things to be completed and help in memory recall.

Checklists, by contrast, are lists of things to be completed or checked. A protocol may be implemented by the use of a checklist, and can be used to facilitate specific treatment guidelines.

When protocols are properly used, clinicians more frequently treat similar patients in a similar fashion. Protocols have the potential to minimize medical errors, decrease the likelihood of injury, increase patient safety and improve patient outcomes.

-Steven Y Chang, Jon Sevransky, Greg S Martin.

Protocols in the management of critical illness. Critical Care, 2012, Vol(16), Number 2, Page 1

Billington EO et al have very rightly pointed out that there could be reasons for variability in clinician behavior; it could be a product of varied educational backgrounds and experience.(Billington EO, Zygun DA, Stelfox HT, Peets AD. Crit Care 2009).

Fessler and Brower, in their study, have concluded that protocols can streamline the care of critically ill patients.

Dr Ved Prakash, a senior doctor with KGMU who heads its Pulmonary and Critical Care Medicine Center, said a chart of all the treatments given at the ICU has been prepared by the hospital. Each and every staff member, including the nursing staff and paramedics, has been asked to follow every step, no matter what the situation.
 

"No one in our ICU can bypass any step as everything has to be recorded and one has to follow every single step to save the life of a patient. We start from the basics and take the advance route only when required," Dr Ved Prakash said.

"We have made it so easy that even a doctor from any other ICU in the world can come here and work easily as everything is written on the chart, such as what medicine is to be given in the primary stage and in what quantity, what the outcome should be and other things. The doctor is also required to record everything on the same chart as we have to bring down the number of deaths in India's biggest ICU," the doctor informed.

Dr Ved Prakash said that all the data of each and every patient has been recorded in the computer and a quarterly analysis is done by them. "We do a quarterly analysis through which we get to know how many lives we have saved and also about the quality of patients' lives. Saving lives is not the only issue here as we have to also see factors like quality of life, economic burden on the family and other things," he explained.

Cleanliness

Dr Ved Prakash said keeping the critical unit clean and free from infections is also very important because of the threat of bacteria and virus present inside the emergency unit.

"A strict instruction has been given to everyone entering the ICU that shoe covers, nose mask, head mask, and gloves are a must and the use of items should not be repeated. The disinfection of the unit takes place once in a fortnight. These bacteria can lead to dreaded things like sepsis which can take the life of a patient," he informed.
 

A nationwide study found prevalence of sepsis within ICUs. One of four patients admitted in ICUs contracted some ailment in hospitals' emergency departments. Almost one out of two patients with sepsis died.

Training

Dr Ved Prakash said they get patients at a late stage in their illness and not in their golden hours. It reduces the chances of saving the life of a patient. Also, he said the ambulance staff is not trained enough to handle critical patients like those in cardiac arrest, accidents, strokes, and other which also affects the mortality rate. To reduce this problem, the ICU has also started to provide training to ambulance staff also.

Training for every staff member, be it ambulance attendants, nurses or paramedic staff, is part of the protocol.

According to 2013 civil registration data released by the Census Directorate, 27% of deaths happen with no medical attention to the patients while a national ambulance code is also being made after it was reported that India's ambulance system has failed drastically and about 40 to 50% of the patients die on their way to the hospital. Following the best practices has enabled the KGMU plug these gaps and maximise a patient's chance of survival.

Article was originally published on April 30, 2018.
 

Disclaimer- The views presented in this article are those of the reporter and not intended to be 'promotional' in nature. The story was contributed by Saurabh Sharma, a Lucknow - based freelance writer and a member of 101Reporters.com, a pan-India network of grassroots reporters. M3 India does not endorse the treatment protocol followed  at the organization.