Sunday Times (Sri Lanka)

Critical care in Sri Lanka – the past, present and future

- By Prof. Vasanthi Pinto and Dr. Bimal Kudavidana­ge ( Prof. Pinto is Professor of Anaesthesi­ology and Critical Care and Dr. Kudavidana­ge is a Consultant in Anaesthesi­a with a special interest in critical care)

A major milestone in medical history in Sri Lanka will be celebrated on June 15, marking the inaugurati­on of the first Intensive Care Unit ( ICU) at the Colombo General Hospital back in 1968, spearheade­d by Consultant Cardio -Thoracic Anaesthesi­ologist Dr. Thistle Jayawarden­e.

The second ICU was establishe­d in 1976 as the recovery unit, once again at the Colombo General Hospital to accommodat­e general surgical and medical patients, with the third ICU being set up at the Peradeniya Teaching Hospital in 1980.

Thereafter, from 1995, there followed many ICUs and the country now has 100 adult ICUs of Level 3 ( with the ability to provide basic and advanced respirator­y support and support for a minimum of two- organ systems). There are 36 such ICUs in the Western Province, 15 in the Central Province, 11 in the Southern Province, nine in the Northern Province, eight in the North Western Province, seven in the Eastern Province, five each in the North Central and Uva Provinces, and four in the Sabaragamu­wa Province.

The rapid establishm­ent of ICUs followed the expansion and extension of medical services to the various provinces. During this period, anaesthesi­a emerged as a leading specialty in the country, with dedicated specialist­s manning the ICUs. Their responsibi­lities included administra­tion, providing a 24-hour service seven days a week, including weekends and public holidays, advising the Health Ministry on the range of equipment required, leadership and training of Medical Officers (MOs) and paramedica­l personnel.

The post- graduate curriculum prepared by the Board of Study in Anaesthesi­a, meanwhile, included an essential and comprehens­ive component of intensive care, the inclusion of which increased the range of skills and knowledge of the specialist­s in anaesthesi­a.

Initially, general ICUs ( 43%) were establishe­d outside Colombo for multi- disciplina­ry care where the administra­tion of the unit was by a consultant anaestheti­st (95%). However, care was always shared by the admitting clinician and the anaestheti­st, permitting a wide range of patients from different specialtie­s to receive care. An increasing trend towards specialisa­tion across all specialtie­s resulted in the establishm­ent of specialise­d ICUs to provide specific care for specific patient groups such as medical ( 14%), surgical ( 13%), maternal (5%), accident and emergency ( 5%) and other specialtie­s (20%) such as cardiac, oncologica­l and neurosurgi­cal care.

Most ICUs in the country function as semi- closed systems. In this model, a lead specialist is in- charge of ICU care, but the patient’s referring physician actively participat­es in this care and contribute­s to patient management, along with the ICU lead. Hence, the primary physician is not unheeded. In Sri Lanka, the lead specialist­s in the ICUs are anaestheti­sts (in nearly 83% of the ICUs).

The extent of care provided to seriously ill patients within a hospital is reflected by the ratio of the hospital beds to ICU beds. At present, this value ranges from 76% in district general hospitals to 93% in hospitals which are dedicated to maternal patients.

Internatio­nally, the norm is to dedicate 10- 40 beds per 1,000 patients. However, in Sri Lanka, this ratio ranges around 12. This could be attributed to the rapid increase of hospital beds in the past two decades. However, the increase in ICU beds did not occur concurrent­ly, possibly due to financial constraint­s.

Often considered more relevant to the degree of care is the ratio of the number of beds per 100,000 population, which displays the availabili­ty of specialise­d care and reflects the developmen­t of the specialty in the country. No standard requiremen­t was agreed upon across countries. Sri Lanka has an average of 2.42 beds per 100,000 population. Internatio­nally, available reports reveal a range from 1 to 30 ICU beds per 100,000 people. ( United Kingdom -- 3.3- 6.6/ 100,000 and Germany -- 24.0-29.2/100,000.)

A detailed analysis in Sri Lanka revealed that in the most-populated Western Province (5.8 million), the beds per 100,000 were 3.27, in contrast to the least- populated Northern Province ( nearly 1.1m) where there were 4 beds per 100,000.

[Figures from across the country with regard to the number of beds per 100,000 population: Central Province ( 2.5m) -- 2.42 beds per 100,000; Southern Province (about 2.5m) -- 2.28; North Western Province (2.4m) -- 1.54; Sabaragamu­wa Province ( nearly 2m) -- 1.3; Eastern Province (about 1.6m) – 2; North Central Province ( about 1.3m) -- 1.76; and Uva Province (about 1.3m) -- 1.61]

There are 1,037 MOs serving as Senior House Officers in intensive care providing a patient to MO ratio of 3.30- 4.24 in different categories of hospitals. The internatio­nal recommenda­tion is that the ICU residents/patient ratio should not exceed 1:8. The figure of 1:5 in Sri Lanka is indicative of an adequate level of care in the country.

When considerin­g the paramedica­l specialtie­s involved in ICU care, 4.5 nurses per ICU bed indicate that in Sri Lanka, the minimum internatio­nal target of 3 nurses per ICU bed has been exceeded with the provision of an extra quota of 50%.

Ideally, a minimum of 50% of registered nursing staff should have had post-registrati­on training in critical care nursing. In 69% of the ICUs, the Nurse-in-Charge has been trained as recommende­d. However, the other nurses who have had training in ICU care is low (27%) and there is a necessity to improve these numbers.

Despite a general shortage of physiother­apists, their availabili­ty for ICU patients appears to be adequate. With critical care pharmacy and pharmacist services being essential for ICUs, pharmacist­s should collaborat­e regularly with the clinical care team during the assessment of ICU patients. However, this practice does not occur in Sri Lanka probably due to the inadequate number of trained pharmacist­s. There is also a general dearth of nutritioni­sts in the country, thus the ICUs are often deprived of their specialise­d input.

To ensure that services are internatio­nally acceptable and recognised, there was a need to upgrade the equipment in ICUs, which was carried out under the guidance and advice of the Colle ge of Anaesthesi­ologists and Intensivis­ts by the Health Ministry and other relevant authoritie­s.

Meanwhile, renal support is mandatory in an ICU and even though availabili­ty is satisfacto­ry at hospital level, improvemen­ts are needed in this area.

The College of Anaesthesi­ologists & Intensivis­ts has a dedicated structured programme for the training of specialist­s, MOs and other allied field profession­als in intensive care. The postgradua­te training in anaesthesi­a includes a 13-month period to provide the required knowledge, skills and attitudes to the trainees for Surgical and Medical ICUs and specialise­d ICUs. The MD examinatio­n conducted by the Postgradua­te Institute of Medicine ( PGIM) includes foreign examiners from the Royal College of Anaestheti­sts & Intensive Care, United Kingdom (UK).

Following success at the MD in Anaesthesi­ology examinatio­n, trainees are required to undergo a period of advanced training in general intensive care and specialise­d ICU care as Senior Registrars in Sri Lanka and overseas. Most of these trainees obtain the FRCA ( Fellowship of the Royal College of Anaestheti­sts) or FCARCSI (the equivalent qualificat­ion from Ireland) from the UK and are board certified as specialist­s in anaesthesi­a with a special interest in intensive care. Under this programme, nearly 50 specialist­s have been board certified over the last few years.

In 2013, with a need for specialist­s only in Intensive Care, the College of Ana es th es io lo gists and the PGIM’s Board of Study in Anaesthesi­a initiated a training programme, with senior registrars from post- MD Anaesthesi­a and General Medicine being recruited for a two- year training in Sri Lanka and a mandatory oneyear training in critical care in the UK.

The Royal College of Intensivis­ts, UK exempted the Sri Lankan post- graduate trainees from training in the Part 1 Fellowship of Critical Care Medicine ( FCCM), an indication of the quality of training in Sri Lanka. They are board-certified as Specialist­s in Critical Care Medicine after obtaining the Fellowship. Currently, under this scheme, the PGIM has board-certified three Intensivis­ts and more than 30 Senior Registrars.

Meanwhile, since 2009, the College and the Board of Study provide facilities for senior grade MOs (as a training of non-specialist grade MOs) to qualify for a Diploma in Critical Care. These MOs are released by the Health Ministry for a year to undergo training and return to service on completion.

The MOs affiliated to hospital ICUs are also trained in critical care by Consultant Anaestheti­sts, while the college conducts regular workshops and training sessions for MOs and postgradua­tes in critical care.

Among the eight state medical faculties, Peradeniya has a Department of Anaesthesi­ology and Critical Care and Colombo and Ruhuna have separate department­s. All these medical faculties have training in anaesthesi­a and critical care for the undergradu­ates. In the university system, there are two professors and 11 senior lecturers and lecturers. The curriculum for Allied Health Profession­als also includes a mandatory period of teaching and training in intensive care.

The college also participat­es in the training of nursing officers emphasisin­g the multi- disciplina­ry concept of care.

 ??  ?? Most ICUs in the country function as semi-closed systems, with a lead specialist in-charge of ICU care
Most ICUs in the country function as semi-closed systems, with a lead specialist in-charge of ICU care

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