Which world do you live in your honor


Honourable Supreme Court has ordered that operations should not be conducted in nursing homes if they do not have Intensive Care Units. This very unfortunate judgment has been delivered in a case involving surgery done more than 23 years ago in a nursing home in which patient required ICU care and hence had to be shifted to another hospital. This judgment is totally out of sync with reality specially in a case which happened in early 1990s when an ICU in India was an emerging concept. That today’s swank corporate hospitals with their 100 ICU beds were not even on the drawing board then is of moot importance .

World over the trend is shifting to minimally invasive Day Care Surgery which reduces medical costs, decreases hospital acquired infections and hence morbidity and mortality. If surgery cannot be done in a nursing home which does not have an ICU then the Day care surgery centres have no role in Indian healthcare scenario. This is a retrograde step both for healthcare as a whole as well as for health economics.

The Cost of healthcare increases with suchlike judgments. Unfortunately the honourable judges seem unaware of the fact that few Ventillators do not make an ICU. An ICU needs an Intensivist with round the clock availability of qualified doctors and specialized nurses under his supervision. Facilities for monitoring, blood gas analysis and round the clock power backup, oxygen supply, and 24 hours laboratory support. Will these SC mandated ICUs have facilities for Ultrasound guided CVP placement which is routine worldwide because tomorrow placing a Central line without U/S guidance will sooner or later be held negligent by our courts. Since pleural tap done without u/s guidance has been declared to be negligent so this is not far fetched . And since U/S will be needed obviously PCPNDT Act will rear its head into every hospital having an ICU.

With 80 % of hospitals conducting surgeries in India being less than 30 bed and run by single doctor or by couples with visiting consultants maintaining an ICU in suchlike nursing homes is an impossibility. The unfortunate part is that this judgment will be referred to as case law and will sooner or later result in either closure of these small and medium healthcare establishments or force them to invest in an ICU which will be non viable. Once a situation arises that such non viable white elephants are forced on the medical entrepreneurs they will be misused to treat patients who do not need ICU care and actual needy patients will still be referred to higher centres.

Since any delivery may need to be taken up for urgent caesarean obviously no delivery should also be undertaken in absence of an ICU. Then there is the issue of what constitutes surgery because even needle penetration of skin to treat a disease has been construed to be surgery by the honourable courts. This would cast the net far and very wide. All Eye hospitals and ENT Centres will need to have and ICU if they have to conduct surgery. Then there is also the issue of Government hospitals where there is bare rudimentary infrastructure in the name of operation theatre what to talk of ICU.

Health care establishments in India are basically of the following types. 
1) Clinic providing OPD services only
2) Day Care Centre with minor procedures
3) Nursing home / Hospital with inpatient facility but without OT / ICU / 24 hour Emergency/ Blood Bank
4) Nursing home / Hospital with inpatient facility and 24 hr emergency but without OT / ICU / Blood Bank
5) Nursing home / Hospital with inpatient facility and OT but without ICU / 24 hour Emergency/ Blood Bank
6) Nursing home / Hospital with inpatient facility, OT and 24 hour emergency but without ICU / Blood Bank
7) Nursing home / Hospital with inpatient facility, OT and 24 hour emergency and ICU but without Blood Bank
8) Nursing home / Hospital with inpatient facility, OT and 24 hour emergency ICU and Blood Bank
9) Teaching Institutes/ Corporate Hospitals

What is needed is to grade the existing healthcare facilities into the above types and to display the same. This would enable patient entering an establishment to know what kind of services are on offer and what facilities are not available. Forcing all nursing homes to either provide ICU or stop conducting surgeries is fraught with danger. This judgment in fact reinforces our demand for doctors only to be on the bench for deciding cases of medical negligence because such a bloomer could only be made by someone not remotely connected with healthcare industry.

Dr Neeraj Nagpal 
Convenor,Medicos Legal Action Group, Managing Director MLAG Indemnity,
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
1184, Sector 21 B Chandigarh 
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NEW DELHI: The Supreme Court has said nursing homes without an intensive care unit facility can't carry out surgeries on a patient as absence of an ICU posed danger to the patient's life.