At the end of his evening tele-ICU rounds to check on Covid-19 patients at an intensive care unit at the KIMS Hospital in Karnataka’s Dharwad district, pulmonologist Dr Raghavendra, sitting in the Columbia Asia Hospital in Bengaluru, tells the doctors in Dharwad about a new study published in the International Journal of Infectious Diseases.
The “Detroit Study”, a multi-hospital study published early July by US researchers, has shown that “treatment with hydroxyally, chloroquine alone and in combination with azithromycin reduces COVID-19 associated mortality”, the doctor in Bengaluru tells the Dharwad ICU.
A tele-ICU facility started by the Karnataka health department in April this year as a “hand-holding exercise” for effective treatment of critical Covid-19 patients at hospitals in various districts of the state has become a key tool in reducing deaths in these hospitals and in keeping doctors in the districts abreast with latest developments in the treatment of the disease.
The tele-ICU facility started across 28 district hospitals has now expanded to 68 hospitals with medical experts from top private hospitals in Bengaluru, like Columbia Asia, Manipal Hospital and Narayana Health, doing everyday rounds of ICUs and discussing treatment for every serious patient.
With the tele-ICU reportedly helping in keeping case mortality rates in some of the districts as low as 0.54 per cent, the health department has now moved to use the services in Bengaluru, which has seen fatality rates as high as five per cent in recent days.
“Tele ICU has helped in reducing mortality in district hospitals. If we look at the statistics across districts – we have provided tele ICU facilities from our hospital to 15 districts — the death rate is 1.33 per cent. In Bengaluru, the death rate was as high as five per cent at one point. By providing tele ICU and effective bed coordination, the death rate in Bengaluru can also be reduced,” said Dr Pradeep Rangappa, an intensive care specialist at the Columbia Asia Hospital, who heads a team of doctors of the hospital involved in the daily tele rounds of ICUs.
“There are two clear benefits of the tele ICU. One is that we are able to provide standardised treatment for patients across hospitals and districts. Second, we keep doctors in various districts abreast of the latest and global developments in the treatment of Covid -19,” Dr Rangappa said.
Treatment protocols have been drawn up with doctors from the state-run Rajiv Gandhi Institute of Chest Disease and are constantly revised and updated with the latest research findings, he said.
All 30 districts in the state have been divided into smaller units and responsibility has been distributed among the three private hospitals – Manipal Hospital, Columbia Asia and Narayana Health — involved in providing the services of doctors for the care of ICU patients in the state.
“Columbia Asia and Manipal Hospital have been on board since the Critical Care Support program began three months ago, and NH has come on board now and will work with Bengaluru hospitals,” said Dr Vasanth Kumar, assistant director with the Karnataka government’s e-hospital initiative.
The tele-ICU interaction between experts from the private sector and district hospitals is moderated on Zoom by health department doctors and a group of interns from medical colleges.
According to the Critical Care Support plan devised by the health department, the external experts will be available every day for an eight-hour shift which includes two tele rounds of the ICUs in the district hospitals in the morning and evening for about two hours each. The experts will also be available on call to resolve issues or address emergencies in the ICUs, as per the CCS plan.
“We started by mirroring the case sheets of the patients from the district hospitals and we are now providing our own inputs for treatment. We are able to ensure availability of any drug or equipment at the district hospital within a short span of time and this helps in treatment,” Dr Vasanth said.
Among the things that the state doctors have found out in the course of manning the tele ICU over the last few weeks is that the drug Remdesivir is very useful in preventing deaths in ICUs and that getting patients with breathing problems to lie in an awake proning position (lying on their stomachs) is a crucial factor in recovery.
“Around 5000 vials of Remdesivir have been received by the state. We just got a call from a district saying they need more supplies. We have coordinated with the local Karnataka Drug Logistics department to supply it. The drug has been effective in helping in recoveries,” says Dr Anil S, a deputy director with the state tuberculosis control program who works evenings at the tele ICU facility.
“Bengaluru has the third largest CF (case fatality) in the country and is worsening indicators for Karnataka. When the state has implemented tele ICUs and reduced deaths in other districts, why is Bengaluru city not adopting it?” the epidemiologist and member of the state technical committee to tackle Covid 19, Dr Giridhar R Babu, said recently on social media.
As of July 21, the Covid-19 deaths per million population in Bengaluru was 74.8 compared to 23.8 in the state. The case fatality rate was, however, on par with that of the state, at 2.1 per cent. The government-run Victoria Hospital in Bengaluru has recorded 97 per cent deaths among patients who were Covid-19 positive and put on ventilators at the hospital ICU.
“Patients in Bengaluru typically had a lot more comorbid problems and in particular CKD (chronic kidney disease) patients were unusually affected severely and had high mortality in Bengaluru compared to districts is what I get to gather,” said Dr Rangappa.
According to state medical education minister Dr K Sudhakar, the tele ICU model used for district hospitals in Karnataka “has been adopted by some states after studying the Karnataka model”.
During a recent inspection of the state-run Bowring Hospital in Bengaluru, the minister insisted on the hospital signing up for tele-ICU services after learning there was a high incidence of deaths in the 165-bed hospital equipped with 15 ICU ventilator beds.
“The battle against Covid 19 is not a battle of the doctors in the private sector alone or the doctors in the government sector alone. In Karnataka, private doctors and public sector doctors are collaborating to effectively treat Covid 19 patients,” said Dr Rangappa.
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