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© JAPI • VOL. 56 • APRIL 2008 www.japi.org 221
Editorial
ICU Care in India - Status and Challenges
ME Yeolekar*, S Mehta**
*Professor of Internal Medicine, Dean and Director (Medical
Education and Research); **Associate Professor of Medicine, Seth
G.S.Medical College & K.E.M.Hospital, Acharya Donde Marg,
Parel, Mumbai-12.
An intensive care unit (ICU) is dened as a specially
staffed, specialty equipped, separate section of a
hospital dedicated to the observation, care, and treatment
of patients with life threatening illnesses, injuries, or
complications from which recovery is possible. It provides
special expertise and facilities for the support of vital
function and utilizes the skill of medical nursing and other
staff experienced in the management of these problems.
The global history of ICU care dates back to the
polio epidemic in 1950s, when the specialty of critical
care was born. Simple ventilators or hand ventilation
enabled the survival of some patients. The technique
of controlled ventilation was then extended to patients
with drug overdose, tetanus, and chest trauma, with
resultant improvement in survival. The development of
effective ventilator and improved circulatory support in
post operative patients radically extended the surgical
possibilities. The ICUs then assumed the role in prevention
of irreversible organ failure. The majority of hospitals
(> 88%) in the United States have one or more ICUs,
constituting 5% or less of the total hospital beds. ICUs in the
United States consume 15% to 20% of the hospital budget,
amounting to 1% of GNP.1
India is a diverse country with different levels of health
care: primary, secondary and tertiary. The rst coronary
care unit in India was started in 1968 at the King Edward
VII Memorial Hospital, Mumbai. This unit was followed
by one at Breach Candy hospital in Mumbai, and later in
other large private hospitals of Mumbai and in other large
cities of India.2 Critical care units in the early 1970s, though
centralized, were designed and equipped chiey to offer
intensive care to patients with acute myocardial infarction
and other manifestations of ischaemic heart disease. There
was a poor concept of overall critical care or intensive
respiratory care. Ventilator support was primitive and was
generally offered as a terminal therapeutic approach. Many
of the ICUs were decient in good monitoring facilities and
were initially offered in a few designated room(s) within
a general ward of the hospital. The number of critical
care units caring for life-threatening illnesses other than
coronary heart disease slowly increased. In mid-1980s
there was a signicant improvement in the standard of
care, particularly evident in the larger teaching and private
hospitals in the cities of India. As a related professional
development, in 1993 the Indian Society of Critical Care
Medicine (ISCCM) was formed, which currently has
around two thousand members.3
The concept of respiratory care, including mechanical
ventilation was still underdeveloped. Initially, a volume-
cycled Beaver's ventilator and later a Bird's ventilator
were used. Critical care beds in the large public teaching
hospitals generally constitute 5-8% of the total bed
strength. At advanced centres in large cities, the ICU bed
strength varies between less than 5% of the total hospital
beds in majority of hospitals, to near 10% in selected few
hospitals. Large public hospitals (e.g., the All India Institute
of Medical Sciences, Delhi, and some corporate/chain
hospitals in the metropolitan cities/state-provincial capitals
of the country) have separate medical, surgical, paediatric,
cardiac, cardiothoracic, neurology, paediatric and neonatal
ICUs. Most hospitals have all/broad purpose ICUs or, at
most , medical, surgical, and coronary care units.
The number of ICU beds available is disproportionately
low, both in private as well as public hospitals. Obtaining a
bed in ICU is quite often difcult for critically ill patients.
Owing to shortage of ICU beds, only the most critical of
the deserving patients are provided ICU care, that could
contribute to high mortality inside the ICU as well as
outside the ICU (in the wards). There appears a strong need
to increase the ICU beds to at least 10% of total beds in all
hospitals; and even upto 15-20% in some leading public as
well as private tertiary care centres. Shortage of ICU beds
has slowed the pace of cadaver organ transplant program
adversely. In India, cadaveric renal transplantation
accounts for less than 1% of total renal transplantations.4
Shortage of ICU beds limits the protocols to be followed
for brain dead patients for organ harvesting. Success of
cadaver organ transplant program may become possible
by creating new and exclusive ICUs for brain dead patients
identified for organ harvesting, under the concerned
departments, e.g. nephrology.
The care in Indian ICUs has evolved from cardiac to
multi-system diseases. Initial ICUs were Cardiac Care
Units, where deaths due to ventricular brillation could
be prevented by DC shock, and temporary transvenous
pacing could be done for heart blocks. In later years, the
scope of ICUs includes thrombolysis in acute myocardial
infarction (AMI), primary and rescue angioplasty, primary
coronary artery bypass surgery, congenital heart surgeries
in high risk underweight babies. Swan Ganz catheterization
has ensured better measurements of pulmonary capillary
wedge pressure and appropriate differentiations into
causes of dyspnoea predominantly cardiac or respiratory
and advanced precise interventions and mechanical
ventilation.
Conventionally, the ICUs are led/manned by respective
medical or surgical specialty e.g. coronary, respiratory,
medical, neurological, neurosurgical, general surgical,
222 www.japi.org © JAPI • VOL. 56 • APRIL 2008
anaesthesia, paediatric, neonatal, burns and dialysis units.
The newer generations of critical care physicians, popularly
known as `intensivists' undergo training to cater to multi-
specialty patients. The paediatric and neonatal ICUs have
come primarily from major teaching hospitals, and partly
in some hospitals in the private sector.5 The newest ICU
set up emerging in some advanced tertiary care hospitals
is the emergency or acute care units, located in the casualty
or emergency departments. These emergency intensive
care units cater to rst 24 hours of aggressive treatment,
monitoring and stabilization of diverse emergencies,
and seem to have signicantly reduced the mortality,
especially in patients with Acute Myocardial Infarction/
ACS, Cerebrovascular Stroke, Adult Respiratory Distress
Syndrome (ARDS) arising out of diverse aetiologies and
poisonings.
The ICU patients across the country show peculiar and
distinct trends. During monsoon, 70-80% of patients are
of infectious diseases (tropical febrile emergencies e.g.
malaria, leptospirosis, dengue). Lifestyle related metabolic
diseases and consequent critical situations are on the rise,
e.g. diabetes, cirrhosis, uraemia. Consistent with the general
demographic trends, 30-40% of patients in ICU are elderly,
with inherent features of difcult weaning, prolonged
stay and refractoriness to standard line of treatment.
Nosocomial infections due to multiple vascular accesses
and tubings, catheterisations are clinical entities of concern,
as are fungal infections in immunocompromised hosts such
as those with HIV/AIDS, uncontrolled Diabetes Mellitus
further accentuated by usage of potent antimicrobials.
The infrastructure and care in ICUs across the country
is varied. Advanced units with proper infrastructure are
available at teaching hospitals and major private hospitals.
On the other hand, small time set up units with just basic
`monitor only' facility are apparently numerous in nursing
homes and small hospitals, where ICUs exist in the most
elementary and somewhat crude situations. Monitoring,
certication and adherence to basic/dened norms is
obviously necessary.
Overall, there are few critical care units in the
country that are well equipped and have the expertise
to use modern, sophisticated technology to the patient's
advantage. Many units are poorly equipped for economic
reasons, and a few units are reasonably well equipped but
lack the comprehensive equipment and/or the expertise
to use it with efciency and discretion. The scenario is
slowly changing for the better in terms of technology and
expertise.
The cost of ICU care in a tertiary care centre in India
(in 1991) was reported to be Rs. 3200 per patient ($167.70).
Stafng, intravenous uids, and drugs accounted for 75% of
the cost of ICU care, whereas 15% accounted for laboratory
investigations and 6.9% for disposables.2 The cost of ICU
care is rising steadily owing to costly equipments and
manpower in better ratios. However, the ICU care of high
quality is available in teaching hospital at highly subsidized
cost to the patients; though the ratio of nursing staff in
government hospitals tends to be sub-optimal.
Critical care units in India face many challenges. Laws/
regulations by the government or the local and national
authorities that determine the standards or efcacy of
a critical care unit need to be in place. More organized
formal training for physicians or nurses in critical care is
necessary today, more than ever before. ICU care is poor or
nonexistent at district hospitals in rural India, which cater
to 80% of the population. Standard protocols and working
SOPs for the staff are both essential and crucial.
While the concept of the intensive care unit has gained
widespread acceptance amongst medical professionals,
hospital administrators and the general public, recognition
of the need and role for doctors specializing in intensive
care medicine, has lagged behind. Many large studies
world over suggest better outcomes in ICUs run by full time
dedicated intensivists.6 Consultant intensivists have been
demonstrated to improve outcomes in terms of morbidity,
mortality, length of stay and costs. Nursing staff have a
more specialized role to play in the ICU set up with a higher
nurse to patient ratio.
The future directions for developing high quality ICU
care in India include upgradation of ICUs, especially in the
less organized sector; increasing the ICU beds to 10-15%
of total hospital beds in public as well as private hospitals;
defining national or state norms for ICUs; regulating
and licensing of ICUs; accreditation from competent
government agency; training of ICU nurses and Intensive
care physicians; technology sharing with developed
countries, funding programs in collaboration with WHO,
ICMR, DBT, NGOs; use of information technology for
patient care, training and research. Setting up acute care
units in emergency departments greatly reduces the door
to intervention time and has the potential to revolutionize
the management of diverse emergencies both infectious
and non-infectious.
Acknowledgement
Manuscript assistance by Aditya M Yeolekar, House physician
Dept. of Chest Medicine, KEM Hospital, Parel, Mumbai 12.
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3. Prayag S. ICUs worldwide : Critical care in India. Critical Care 2002;6:479-
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4. Feroz A. Cadaveric renal transplantation: our experience at the Institute
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