Sunday Times 2
Critical care in Sri Lanka – the past, present and future
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.
Most ICUs in the country function as semi-closed systems, with a lead specialist in-charge of ICU care
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 College 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 Anaesthesiologists 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 one-year 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.
(Prof. Pinto is Professor of Anaesthesiology and Critical Care and Dr. Kudavidanage is a Consultant in Anaesthesia with a special interest in critical care)