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4683Fwd: [iami] Re: Transparency and efficiency in health care: Meeta Rajib Lochan, Secretary, Health

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  • Rakesh Biswas
    Mar 25, 2014
    • 0 Attachment
      Thanks Senthil, Monika, Kinjal and Thanga for these inputs. Also sharing with IAPSM where i originally found the article link. Senthil your study on 'early detection of sepsis' could also be very useful for the community (other than the hospital settings where it appears to have been initiated)? We have utilized simpler tools such as fever charting and a check list to rule out sepsis and prevent antibiotic overuse in the community (initially in Bangalore http://www.ncbi.nlm.nih.gov/pubmed/17576636...commonest community acquired bacterial sepsis is possibly Salmonella as in the patient linked below) and we also extended this recently to Bhopal (with a better study design as part of a PG thesis) with gratifying results that showed we can effectively rule out (if not rule in) sepsis and prevent antimicrobial overuse. Will be looking forward in future to better use of pattern recognition tools such as automated fever charting and communication through mobile devices as further extension of 'information sharing' as an effective-intervention to optimize healthcare.

      best,

      rakesh


      From: Senthil Nachimuthu <nachimuthu@...>
      Date: Wed, Mar 26, 2014 at 2:34 AM
      Subject: Re: [iami] Re: Transparency and efficiency in health care: Meeta Rajib Lochan, Secretary, Health
      To: IAMI All <iami@yahoogroups.com>
      Cc: Monika Pathania <anshupathania27@...>


      Whether you get positive cultures or not depends on whether you draw blood cultures before starting antibiotics. In any case, evidence shows that sepsis is a condition with relatively high probability of positive blood cultures - more than 70% (see Bates et al, 1997, PubmedID:9395366 and Rangel-Frausto et al, 1995, PubmedID: 7799491). I'm not sure about your cohort's size, inclusion criteria, findings, etc, but can you share it please. However, sepsis is defined by the presence of Sysemic Inflammatory Response Syndrome (SIRS), and either suspected or confirmed infection. So, a positive culture is not required to diagnose sepsis. Finally, the infection may be localised, so even a patient with sepsis may get negative blood cultures in spite of an infection.

      I must also note that with SIRS alone, we can diagnose sepsis with reasonable accuracy. In my experience, a machine learning method based on Dynamic Bayesian Networks using SIRS data elements detected sepsis better than just using the SIRS rules. See Nachimuthu and Haug 2012, PubmedID: 23304338, full text at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540576/)

      Finally, I'm involved in a project that collects nationwide antibiotic susceptibility data funded by CDC (US), that answers many questions raised by the newspaper article that Dr. Biswas shared. Meanwhile, you can find many informative reports here - http://www.cdc.gov/nhsn/index.html - hope this provides some inspiration to other researchers and implementers in the IAMI community. I'll keep the group posted when we publish our findings.

      Regards,

      Senthil.

      From: Monika Pathania <anshupathania27@...>
      Date: Wed, Mar 26, 2014 at 1:44 AM
      Subject: Re: Transparency and efficiency in health care: Meeta Rajib Lochan, Secretary, Health
      To: rakesh7biswas@...
      Cc: iami@yahoogroups.com


      Thanks sir.That's very informative report. perhaps this is the first time i ve seen salmonella positive culture and sacroillitis associated wid it.i hope she didn't have any hemoglobinopathy. In low resource setting where malaria is not endemic like in garhwal hills , where we work, typhoid is our firsst diagnosis but till now i haven't seen a single bloodculture positive for typhi.ofcourse we treat them empirically for it and they respond but that doesnt give any evidence and so medical record keeping in this area suffers. I think even hospital with good resources also have same situation in several parts of the country.




      On Mon, Mar 24, 2014 at 8:30 PM, Rakesh Biswas <rakesh7biswas@...> wrote:
       

      Thanks Monika, Let me know your thoughts on this record of a hospital based patient (followed up in the community) who had a sepsis that also turned to be culture positive (and a lot of other investigations that couldn't be done due to the low resource settings) also documented in the learning discussion part of the online record linked here:http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1096

      best,

      rakesh


      On Tue, Mar 25, 2014 at 12:08 AM, Monika Pathania <anshupathania27@...> wrote:

      I have rarely seen any blood cultures positive in patients with suspected sepsis. There are very few research institute s where in they record all this. Most of the times we are treating empirical ly.what's the solution?

      From: Kinjal Vora <kinjalvora@...>
      Date: Tue, Mar 25, 2014 at 6:44 PM
      Subject: Re: [iami] re: Transparency and efficiency in health care: Meeta Rajib Lochan, Secretary, Health
      To: iami@yahoogroups.com

      Very good article. Transparency and standardization are very much needed in today's health care setting in india.

      Thanga, RCA (root cause analysis) is only a part of the equation. Recommendations stemming from a RCA need proper execution and need to be reviewed/analyzed on a regular basis for impact and further improvements. Accountability is equally important.
      Are the implementations having the desired outcomes?

      I am saddened to hear about the lack of a patient centric approach in the Indian health care system when I hear experiences from family and friends in india.

      The US system is not optimal but it does have a comprehensive patient centric approach, multi disciplinary approach, coordinated care. In India the patient is left to fend for himself and coordinate his own care.

      Personally i have asked family and friends to change their physicians if they do not explain and provide satisfactory information about their condition and treatment choices.

      Kinjal

      From: thanga prabhu <thangas@...>
      Date: Tue, Mar 25, 2014 at 5:53 PM
      Subject: Re: [iami] re: Transparency and efficiency in health care: Meeta Rajib Lochan, Secretary, Health
      To: iami@yahoogroups.com


       
      So very true Rakesh...I am a firm believer of this fact. When I learnt State Govts return around 60% of the funds allocated to them from the Centre UNSPENT, it was a revelation and difficult to comprehend to this day. Does it mean there is a need for Consultancy to guide spending? An opposite of that is when senior officials in one of the more progressive states said to me dont worry about Funds, we want solutions. They went on to enlist World Bank, UNICEF and their own budget allocations as sufficient. Is it a surprise that IMR/MMR have dropped significantly in this state? The clue lies in one fact: The NRHM mission director was an MBBS Dr who was also IAS, so he knew the problems first hand and had power to solve them. This is not restricted to bureaucrats or technocrats...YSR was a medic. He asked his team to put together a health insurance model which would give procedure access to patients without worrying about cost. Arogyasri was born, see it in action in AP today!

      As Patients we must demand Quality, as Doctors we must provide Quality. Reforming the healthcare system starts at home. Public health and Preventive medicine should take precedence over Curative medicine (Healthcare Vs Sickcare). Priamry care should manage all but those cases which require surgery/specialized care. NABH is doing wonders in driving up Quality though JCI is an expensive alternate. Documentation is key in both systems.

      Throwing more money at the problem without doing a RCA (root cause analysis) doesnt solve anything. US healthcare can be a good lesson in failure as mentioned in the article. All countries are trying to reform their healthcare systems...India is truly the place where solutions will emerge. It is in our nature to be frugal, innovative and find simple solutions to complex problems. There is an article in today's TOI of twenty year old kids building a rocket to launch cansat (a satellite that fits in a can of redbull). NASA launch costs run into millions, ISRO's bill is 1/10th of that and these kids may just beat that too! bravo India, chuk de!  



      Dr Thanga Prabhu
      Indian Association for Medical Informatics - iami.org.in
      American Medical Informatics Association - amia.org
      International Ambassador - Swansea University, UK

      Cell: +91 98866 83690

       
      On 24 Mar 2014 20:08, "Rakesh Biswas" <rakesh7biswas@...> wrote:
      Interesting insights from Meeta Rajib Lochan:

      Few people know that hospitals simply do not keep the kind of records that might provide them feedback on the quality of patient care. For example, in case any incidence of infection is recorded, it would be recorded on the case paper of the individual patient. This information is not filed in any central registry. Correspondingly, no corrective action at the institutional level is possible other than that which the immediate caregivers might offer. Merely keeping such records would in itself create an incentive to improve patient care. No doubt, anonymity should be maintained about medical errors outside the hospital. But surely, the caregivers should know what went wrong and where.

      The quality of care standards in hospitals rarely focuses on the patient or functions in the interest of the patient. From a demand side perspective, the reason for this could be that we as patients tend to associate quality with infrastructure. Commonsense says that an expensive hospital is better than one’s neighborhood clinic.

      However, health care is so dependent on human beings that price is no index of quality. Unfortunately, doctors alone cannot ensure success; institutional backing is needed. If only hospitals were to be evaluated just as much on the incidence of post-operative infections as on the reputation of the doctor, hospitals would be much safer places for all users.

      Accreditation and benchmarking is far less about upgrading infrastructure and more about following standard processes. Small can be beautiful in healthcare and excellent quality healthcare can be delivered in low-cost settings too. Most quality of care standards are rather basic: what is the ratio of nurses to patients in the ICU; whether the nurses deployed are actually trained in hospital care; does the operation theatre have an uninterrupted supply of power and water; are lab instruments routinely calibrated, etc.

      http://indianexpress.com/article/opinion/columns/spending-wont-make-it-better/


      best,


      rakesh