Thursday, August 25, 2011

Simulation and clinical skills development









It is acknowledged worldwide that simulation training is an useful and value-added precursor to actual clinical work for healthcare workers.

Simulation is becoming a norm and an essential part of pre-clinical training in several countries and reputed institutes worldwide. Some examples:

2. EISE ( Ethicon Institute of Surgical Excellence) , India
3. Medical Simulation Centre, Rhode Island Hospital

The Apollo Group of Hospitals has set up a clinical simulation centre at Hyderabad. In addition, Defence R & R Hospital, Delhi and AFMC, Pune have facilities for clinical simulation.



Presenting a conceptual note on Clinical Simulation Centres:


1.CPR (Cardiopulmonary Resuscitation) Lab :
This would be utilized for BLS, ACLS, NALS and PALS classes. CPR mannequins are used, which provide training in CPR, AED use, and the Heimlich maneuver. Airway, breathing and circulation systems are simulated and the results of interventions can be demonstrated.
A CPR mannequin for practicing cardiopulmonary resuscitation of a human has a simulated human head and neck portion with an air passage extending from a mouth opening to a neck opening in an end of the neck remote from the head. An inflatable simulated human chest portion is secured to the neck and has an upper flexible wall member, a lower wall member and a flexible bag there between and a further air passage connects the air passage in the neck to the flexible bag. The upper flexible wall member simulates a chest which rises and falls with inflation and deflation of the flexible bag.
The types of mannequins required would be-
a) Adult mannequin for BLS
b) Adult mannequin for ACLS
c) Pediatric mannequin for PALS
d) Neonatal mannequin for NALS
Other than these, the following would be required-
e) 3 demonstration rooms with Seating Capacity for 20 people each.
f) Audiovisual equipment

2. Airway Management Lab
This would be utilized for teaching of airway management to physicians, nurses and paramedics. It would be provided with a
variety of simulators including pediatric and neonatal models.
A mannequin such as the Human Patient Simulator (HIPS) system is used, which contains a self-regulating pulmonary system which regulates the body’s O2 requirements and rate of CO2 production and automatically adjusts the respiratory rate and tidal volume. Breath sounds are auscultated by standard stethoscopes in several locations to detect abnormalities. A number of techniques can be taught using the anatomically correct airway. Bronchoscopy can be performed in the upper airway and trachea. Nasal or oral intubation can be performed. Ventilation can be compromised by tongue or upper airway swelling, bronchospasm, or laryngospasm. If an esophageal intubation is performed, the stomach swells up when ventilated.
During a tension pneumothorax, the adult manikin allows either needle decompression or chest tube placement. The treatments are performed through the computer interface for the pediatric manikin.

i. Access Management Lab
Access Lab would have realistic models for both peripheral and central venous devices, placement of Intercostal catheters, and Spinal Punctures, Regional Anesthesia etc. The mannequin would simulate vascular access and fluid management. Infusions of whole blood, packed cells, crystalloids and colloids independently (artificial solutions), can be carried out. The patient can lose either whole blood or plasma, to simulate the different effects of blood loss through active bleeding versus volume loss through leakage into extracellular spaces.

ii. Emergency and Trauma Management Skills Lab
Trauma management skills are taught using mannequins, audiovisual aids and life support stations.

iii. General Surgical Skills Lab
It provides simulated hands on surgical skills to a minimum of 15 learners at the same time. Each student is able to see the skills being taught by the teacher, on the monitor and then perform the same at his/her station. All the skills are supervised by a team of dedicated trainers.

iv. Laparoscopic Surgery Skills Lab
This would contain a Laparoscopic Trainer station that includes an introductory board, several anatomic models, and a camera for training in laparoscopic surgery skills. Trainees begin on the introductory board. Stations demonstrate basic skills which will be incorporated into many real surgical procedures. Once the trainees are comfortable in the laparoscopic environment, the introductory board is removed and various surgical anatomic models are placed in the trainer, each of which will be used to teach operating techniques or full length procedures.


v. Endoscopic Skills Lab ( Lower GI / Upper GI endoscopy)
This would contain a endoscopic model, consisting of a endoscope, a box containing the computer components, and a screen to view images. Cases are grouped, to allow trainees to focus on basic principles (introduction module) or to learn biopsy or polypectomy procedures. Within all modules, the simulator gives instructional information beforehand, real time patient feedback during the simulation, and constructive feedback after the simulation has been completed.
The endoscope is shaped like a real colonoscope, including all the directional controls and adjunct buttons. The functionality has been removed from the scope, although the simulator senses what the user is doing and causes the image to change appropriately. During the case, the simulated patient responds in real time to the trainee's actions, both verbally and with vital sign changes. The modules contain a series of videos and text instructions.
vi. Bronchoscopic Skills Lab
The fiberoptic bronchoscopy simulator consists of an anatomic model of the face, with an opening in one nare for nasal insertion of the fiberoptic bronchoscope. It has an attached motion sensor system and a video system with screen for the images. As the user inserts and manipulates the bronchoscope, the simulator senses the movements and adjusts the screen images in real time. The respiratory tree and the full length of the bronchoscope are visible as it is currently positioned.
Feedback is given during the procedure (such as an audible patient cough if topical anesthetic is insufficient) as well as after the procedure is complete. Other output is intended to help the trainee develop a personal technique (such as the order the bronchial segments were visited).
Modules within the bronchoscopy simulation include basic maneuvers, lesion visualization, bronchial lavage, and tumor biopsy. There is also one pediatric difficult airway module.

3. Cath Lab, Imaging Lab, Neuroelectrophysiology Lab and other Labs as identified would be required.

In addition, Demonstration Rooms, Lecture halls and Audiovisual Aids would be required for teaching.

Friday, August 5, 2011

New hospital new thinking

 Sharing the story of how NHS Wolverhampton, UK, met patients's expectations:
http://www.ashridge.org.uk/website/IC.nsf/wFARATT/New%20Hospital%20New%20Thinking/$file/hospthink023.pdf

Who said doctors can’t be ethical and successful?

(This article was published in The Hindu on July 24, 2011)

-By Dr. K.R. Antony




When doctors enrolled themselves in the profession, they are bound to observe certain professional ethics and decorum. That is not for sainthood but for the upkeep of a certain code of professional conduct which was practised by our seniors. That gave us the social recognition and dignity we earned collectively.
Now there is value erosion, everybody admits. Breach of medical ethics is seen not as grave, restrained and punished timely, but is being overlooked and condoned easily as an “inevitable evil of the prevailing conditions.”
The strength of the majority is not used to correct the wrongdoing of a minority, but to justify its misdeeds and approval by the whole body as a “survival strategy.” Professional associations are also resorting to strikes to safeguard their business interest and protection from the “public” whom they are supposed to serve. The old fashioned and the not-so-smart ethically practising doctors are becoming a minority. Even a laughing stock! No wonder, the same society that treated us once as “god” is now treating us as “dogs” as lamented by Dr. Manorama Gadde (Open Page, The Hindu, July 17, 2011).
Who is at fault? Rather than taking it to the “media” accused of using “doctors as punching bags,” it is high time for introspection.
What happens, for example, if we refuse to pay 25 per cent of the fees to the local RMPs to get referral cases? My firm belief is that if a doctor is ethical, skilled and very good in his/her profession, people flock to that doctor. Client satisfaction is the best advertisement for a doctor or hospital. People may be unlettered, but their wisdom can differentiate the bad from the good doctor. It is only the mediocre and below average who need advertisement props.
I have seen very poor patients travel from far off tribal areas and districts and across State borders to Ganiari near Bilaspur city to receive the good services of a group of committed specialist doctors who passed out of the AIIMS, Delhi. These doctors do not even put up a decent nameboard.
I started paediatric practice in a 150-bed mission hospital in a rural area where not more than five or six patients came a day. Within a few months, the number grew up to almost 90, and it became unmanageable for me as a specialist to give quality time and attention to my patients. Finally, I was compelled to restrict my outpatient tokens.
Many local practitioners referred patients to me, instead of to the district headquarters hospital, because they knew I did not pass any remark on the missed diagnosis or the not-so-correct case management by the referring doctor. Moreover, would get a return referral slip, in a sealed cover, on what the diagnosis turned out to be upon investigation and the lines of management that I followed.
In India, no qualified doctor willing to practise ethically is going to starve. There is enough revenue generation from consultancy for everybody’s need, but may be not enough to everybody’s greed. The “greed” is often perceived and firmly believed as “need” when you actually embark upon certain ambitions of life for the sake of survival in cut-throat competition. One more building block, one more operation theatre, a CT scan machine and similar sorts, for which banks are ready to advance loans fast but also quick to retract when EMIs are delayed. The stress is passed on to the middle class patients who might not have actually needed it at all. Why join that rat race?

(The writer is a former Health & Nutrition Specialist for UNICEF and former Director, State Health Resource Centre, Chhattisgarh. His email id is krantony53@gmail.com)

Tuesday, August 2, 2011

Health Insurance – A Perspective


 
Dr L Rathika MBBS DFH


With escalating costs, healthcare has become a high priced commodity. In the changing economic scenario, health insurance is no longer a luxury, but indeed a necessity.  More and more households are opting for health insurance cover to tide over the unexpected hospitalization expenses. Nowadays, it is a common practice for employers to provide group health insurance coverage to their employees.
Indian Scenario
Indian Healthcare Industry contributes significantly to the country’s gross domestic product (GDP). In recent years, the concept of health insurance is receiving increasing prominence in India.  According to current research, health insurance market constitutes the second largest non-life insurance sector in India and has registered phenomenal growth in 2008-09 and 2009-10. Health insurance industry is one the fastest growing businesses and the premium mark is expected to cross a compound annual growth rate (CAGR) of 25% by 2013-14.

                                            

Health Insurance

Health insurance is a product that protects the insured person against the risk of incurring medical expenses and provides with specified sums to cover the treatment costs. In India, most health insurance policies cover only hospitalization expenditure.
Need for Health Insurance Cover
Most of the Indians receive healthcare through state owned primary care centers, as well as secondary and tertiary hospitals.  Nevertheless, only 6% of GDP is spent on healthcare. Poor state of government-owned healthcare facilities and the fewer number of hospitals per 1000 population as compared to global average have led to the exponential growth of private secondary and tertiary care hospitals, which constitutes nearly 80% of the country’s health infrastructure. This, among others has contributed to the escalation of healthcare costs. In addition, massive population growth is straining the already over stretched health infrastructure. Socio-economic changes such as ongoing migration of people from rural to urban areas in search of livelihood, sedentary life style, globalization and stress have contributed to the increased incidence of life style diseases such as diabetes and hypertension. Given this background, the need for health insurance is more prominent than ever, considering that merely 10% of Indian population has health insurance coverage.

Advantages and Disadvantages of Health Insurance Policy

Health insurance policy covers the risk of unexpected expenditure resulting from medical treatment. Most insurance providers offer cashless facility of claim settlement when the insured person gets admitted in the hospitals belonging to their preferred provider network, the details of which are made available while purchasing a health insurance policy. There are various health insurance products in the market, offering consumers with a wide range of choice to suit their specific requirement.  Some insurance providers offer discount on the premium amount for the succeeding year, if no claim has been made in the previous year on the policy.

More often than not, health insurance policies cover only hospitalization expenditure, and the cost of outpatient treatment is not generally covered. Moreover, most policies exclude the pre-existing diseases for varying periods of time when the policy is in force, and this makes it wiser to purchase the insurance cover at an early age. One of the exceptions is Star Health – Senior Citizen Red Carpet Policy, which offers coverage of all pre-existing diseases from the first year of policy. In addition, hospitals tend to charge health insurance policy holders at rates higher than the reasonable treatment cost, requiring the insured person to spend additional sums from his pocket.
Public and Community Health Insurance Schemes

The Government of India has increased the plan allocation for the healthcare expenditure from US$ 4.97 billion in 2010-11 to US$ 5.96 billion in 2011-12. Furthermore, the Ministry of Health & Family Welfare has proposed to increase the domestic healthcare funding by at least 2 per cent of the GDP in the 12th Plan period. Taking into cognizance the need for greater population health risk coverage, the central and state governments in India have launched innovative health insurance schemes to help the poor. Rashtriya Swasthya Bima Yojana (RSBY) was introduced by the Government of India for BPL (below poverty line) population in the unorganized sector in April 2007. Recently the government has approved extension of RSBY to cover registered domestic workers, which is likely to cover 47.50 lakh workers. Some of the popular insurance schemes run by the state governments include Aarogyashri in Andra Pradesh, Chief Minister’s Health Insurance Scheme in Tamil Nadu and Yashaswini Insurance scheme in Karnataka.

In addition, several community-based health insurance schemes are run successfully by NGOs across the country and a few of them are listed below.
·         Self Employed Women's Association, Ahmedabad, Gujarat (1992)
·         Goalpara, Shantiniketan, Rural West Bengal (1984)
·         Voluntary Health Services (VHS), Medical Aid Plan, Chennai, Tamil Nadu(1963)
·         Social Work and Research Centre (SWRC), Ajmer, Rajasthan ( 1972)
·         Sewagram Kasturba Hospital, Wardha, Maharashtra (1972)

Leading Health Insurance Providers in India

Though successful, existing health insurance schemes do not cover all sections of the society, thus leaving the field open to private players. Currently we have public sector general insurance companies and private insurance companies offering health insurance products. Of these Star Health Insurance is the only stand alone health insurance company. Leading health insurance providers in India include,
·         National Insurance company
·         ICICI Lombard Insurance
·         TATA AIG Insurance
·         Bajaj Allianz Insurance
·         Max Bupa Health Insurance

Popular Health Insurance Products

Some of the most innovative and popular health insurance products are,
·         National Insurance – Varishta Mediclaim
·         New India Assurance – Mediclaim policy
·         United India – Family Medicare
·         Oriental – Individual Mediclaim Policy
·         Max Bupa – Heart Beat Gold, Silver and Platinum
·         Bajaj Alliance – Health Guard
·         Apollo  Munich – Easy Health Individual -Standard Plan

Future of health insurance in India

Indian health insurance industry is on the verge of an exponential growth. Key factors driving this industry include escalating healthcare costs with resultant need to purchase private health cover to supplement public schemes;   sub-optimal quality of public health services;  booming population growth; increasing incidence of lifestyle related diseases; greater awareness and affordability among the educated middle class;  and deficiencies in pension schemes.

In conclusion, from the consumer stand point, it would be only prudent to purchase health insurance cover for the individual as well as the family earlier the better!