Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study
Virendra Singh, Subhash Todi, Samir Sahu, Charu K. Jani, Atul P. Kulkarni, Devi Prasad Samaddar, Pravin R. Amin, Farhad N. Kapadia, Sujata Mehta, BD Bande, Reshma Tewari, Prachee Sathe, INDICAPS Study Investigators
Adult, case-mix, India, intensive care, practice
Citation Information :
Singh V, Todi S, Sahu S, Jani CK, Kulkarni AP, Samaddar DP, Amin PR, Kapadia FN, Mehta S, Bande B, Tewari R, Sathe P, IS. Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2016; 20 (4):216-225.
Aims: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs).
Patients and Methods: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs.
Results: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality.
Conclusions: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.
Karnad DR, Lapsia V, Krishnan A, Salvi VS. Prognostic factors in obstetric patients admitted to an Indian intensive care unit. Crit Care Med 2004;32:1294-9.
Krishnan A, Karnad DR. Severe falciparum malaria: An important cause of multiple organ failure in Indian intensive care unit patients. Crit Care Med 2003;31:2278-84.
Parikh CR, Karnad DR. Quality, cost, and outcome of intensive care in a public hospital in Bombay, India. Crit Care Med 1999;27:1754-9.
Merchant M, Karnad DR, Kanbur AA. Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India. J Hosp Infect 1998;39:143-8.
Agarwal R, Handa A, Aggarwal AN, Gupta D, Behera D. Outcomes of noninvasive ventilation in acute hypoxemic respiratory failure in a respiratory intensive care unit in North India. Respir Care 2009;54:1679-87.
Chawla R, Sidhu US, Kumar V, Nagarkar S, Brochard L. Noninvasive ventilation: A survey of practice patterns of its use in India. Indian J Crit Care Med 2008;12:163-9.
Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian society of critical care medicine. Indian J Crit Care Med 2014;18:575-84.
Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619-36.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.
Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286:1754-8.
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine 1992. Chest 2009;136 5 Suppl: E28.
Mani RK. End-of-life care in India. Intensive Care Med 2006;32:1066-8.
Mani RK, Mandal AK, Bal S, Javeri Y, Kumar R, Nama DK, et al. End-of-life decisions in an Indian intensive care unit. Intensive Care Med 2009;35:1713-9.
Kapadia F, Singh M, Divatia J, Vaidyanathan P, Udwadia FE, Raisinghaney SJ, et al. Limitation and withdrawal of intensive therapy at the end of life: Practices in intensive care units in Mumbai, India. Crit Care Med 2005;33:1272-5.
Barnett VT, Aurora VK. Physician beliefs and practice regarding end-of-life care in India. Indian J Crit Care Med 2008;12:109-15.
Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med 1998;26:1793-800.
Vincent JL, Marshall JC, Namendys-Silva SA, François B, Martin-Loeches I, Lipman J, et al. Assessment of the worldwide burden of critical illness: The intensive care over nations (ICON) audit. Lancet Respir Med 2014;2:380-6.
Phua J, Koh Y, Du B, Tang YQ, Divatia JV, Tan CC, et al. Management of severe sepsis in patients admitted to Asian intensive care units: Prospective cohort study. BMJ 2011;342:d3245.
Rhodes A, Phillips G, Beale R, Cecconi M, Chiche JD, De Backer D, et al. The surviving sepsis campaign bundles and outcome: Results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med 2015;41:1620-8.
Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Peñuelas O, Abraira V, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 2013;188:220-30.
ISCCM Courses. Available from: http://www.isccm.org/courses.aspx. [Last accessed on cited 2015 Dec 28].
Brilli RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, et al. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19.
Critical Care Delivery in Intensive Care Units in India: Defining the Functions, Roles and Responsibilities of a Consultant Intensivist: Recommendations of the Indian Society of Critical Care Medicine Committee on Defining the Functions, Roles and Responsibilities of a Consultant Intensivist. Available from: http://www.isccm.org/images/ISCCM%20Intensivist%20guidelines.pdf. [Last cited on 2015 Dec 28].
Weled BJ, Adzhigirey LA, Hodgman TM, Brilli RJ, Spevetz A, Kline AM, et al. Critical care delivery: The importance of process of care and ICU structure to improved outcomes: An update from the American College of critical care medicine task force on models of critical care. Crit Care Med 2015;43:1520-5.
Wilcox ME, Chong CA, Niven DJ, Rubenfeld GD, Rowan KM, Wunsch H, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med 2013;41:2253-74.
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002;288:2151-62.
Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and appointing an intensivist in a developing country. Crit Care Med 2005;33:299-306.
Chittawatanarat K, Sataworn D, Thongchai C; Thai Society of Critical Care Medicine Study Group. Effects of ICU characters, human resources and workload to outcome indicators in Thai ICUs: The results of ICU-RESOURCE I study. J Med Assoc Thai 2014;97 Suppl 1:S22-30.
Hanson CW 3 rd, Deutschman CS, Anderson HL 3 rd, Reilly PM, Behringer EC, Schwab CW, et al. Effects of an organized critical care service on outcomes and resource utilization: A cohort study. Crit Care Med 1999;27:270-4.
Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, et al. Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med 2014;42:344-56.
Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med 2008;148:801-9.
Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302:2323-9.
Prayag S. ICUs worldwide: Critical care in India. Crit Care 2002;6:479-80.
Kerlin MP, Small DS, Cooney E, Fuchs BD, Bellini LM, Mikkelsen ME, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013;368:2201-9.
Wilcox ME, Harrison DA, Short A, Jonas M, Rowan KM. Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: A retrospective cohort study. Crit Care 2014;18:491.
Sevransky JE, Checkley W, Herrera P, Pickering BW, Barr J, Brown SM, et al. Protocols and Hospital Mortality in Critically Ill Patients: The United States critical illness and injury trials group critical illness outcomes study. Crit Care Med 2015;43:2076-84.