Since times immemorial hospitals are considered as temples of healing
and people all over the world literally worship the doctors. However,
the rapid industrialization and advancement in technologies have made
hospitals more commercial in their outlook and too much
business-oriented. Health insurance coverage is increasing and with
better awareness and more funds at their disposal people have a wider
and better choice of health care providers.
In the metropolitan
city of Mumbai, we have a chain of corporate hospitals delivering
quality health care at competitive rates. With the advent of medical
tourism and health insurance, it is imperative that the hospitals
deliver standard care at competitive rates.
High quality health
care is only possible with the latest state-of-the-art technology backed
by the best medical brains. Health care technology is undergoing a
rapid metamorphosis, i.e. what was latest yesterday could become
redundant today.
Hence, the need comes for acquiring the best
available technology. Some of the corporate hospitals of Mumbai have the
latest state-of-the-art technology backed by some of the best brains in
the business, with the latest state-of-the-art interiors. Some of them
are so well designed that one does not feel it is a hospital.
Within
hospitals, the unnecessary use or overuse of antibiotics encourages the
selection and proliferation of resistant and multiply resistant strains
of bacteria. Once selected, resistant strains are favoured by
antibiotic usage and spread by cross-infection. Where resistance is
encoded on transmissible plasmids, resistance can also spread between
bacterial species.
There is thus a link between antibiotic use
(or abuse) and the emergence of antibiotic resistant bacteria causing
hospital-acquired infections. It is not possible to completely eliminate
this evolutionary phenomenon, but it can be slowed or modified by
prudent antibiotic use. This requires the inclusion of an antibiotic
policy in the infection control programme.
Antibiotic policy
An
antibiotic policy will improve patient care by promoting the best
practice in antibiotic prophylaxis and therapy. It makes better use of
resources by using cheaper drugs where possible. It can retard the
emergence and spread of multiple antibiotic-resistant bacteria. It also
improves education of junior doctors by providing guidelines for
appropriate therapy, and eliminates the use of unnecessary or
ineffective antibiotics and restrict the use of expensive or
unnecessarily powerful ones.
Antibiotic committee
The
medical director and hospital administrator should ensure that the
hospital plan for prevention and control of nosocomial infection
includes an official committee that has responsibility for the
formulation and supervision of an antibiotic policy. This might be a
subcommittee of the hospital Drugs and Therapeutics Committee or of the
Infection Control Committee. The Antibiotic Committee should have the
support of the medical director and the authority to ensure that its
policies are implemented throughout the hospital.
Membership of
an antibiotic committee may vary according to local conditions and
needs. The committee should be responsible for producing general
guidelines and policies for the health care areas after wide
consultation with the users.
If possible, the following key persons should be included in the committee:
? The pharmacist who will report back to the Antibiotic Committee at each meeting on drug utilization and cost.
? The microbiologist who will report on antibiotic susceptibility patterns of bacteria isolated from major infections.
?
Clinical doctors and nurses responsible for direct patient care who
provide a link between clinical practice and the Antibiotic Committee.
? Manger(s) that will ensure the resources are available for implementation of the antibiotic policy.
? Reciprocal membership between the Infection Control Committee and the Drugs Committee should be ensured.
The
Antibiotic Committee will have to make rational choices amongst
"equivalent drugs" and classes of drugs in order to select the least
expensive, most effective agents. Cost should determine the selection,
when microbiological, pharmacological, and other relevant properties are
similar.
Guidelines
A major task of the Antibiotic
Committee will be to establish guidelines for antibiotic use. This will
lead to production of a formulary that restricts agents available to the
minimum number needed for most effective therapy.
The
guidelines should be drawn up after wide consultation and agreement in
the hospital. It must be simple, clear and short, and ideally published
in a booklet small enough to be carried in a pocket. To be provided to
all newly appointed doctors and nurses and readily available in the
hospital, for example, available on wards. It should contain guidance on
antibiotic prophylaxis (e.g. in surgery with details of timing, route,
dosage and frequency), also it should contain guidance on the choice of
antibiotics for empirical and targeted therapy of major infections, and
also should indicate first and second line therapy for common infections
(might limit the use of certain second line drugs to consultant
prescription only).
Good practices
? Consider whether or not the patient actually requires an antibiotic.
? Avoid treating colonized patients who are not actually infected.
? In general do not change antibiotic therapy if the clinical condition is improving.
?
If there is no clinical response within 72 hours, the clinical
diagnosis, the choice of antibiotic and/or the possibility of a
secondary infection should be reconsidered.
? Give the antibiotic for the minimum length of time that is effective.
? Review the duration of antibiotic therapy after 5 days.
?
Consider the use of pharmacy ‘stop' policies, where drugs are written
up for a specified period and are then only continued if a new
prescription is issued.
? For surgical prophylaxis start the antibiotic with the induction of anesthesia and continue for a maximum of 24 hours only.
Reports of antibiotic susceptibility
The
clinician should receive reports of antibiotic susceptibility based on
the drugs available in the agreed formulary. The testing should be
performed with a limited number of antibiotics selected to optimise
patient care and cost effectiveness. The report should also indicate
where organisms are invariably resistant (e.g., methicillin-resistant S.
aureus are resistant to all beta-lactams).
The Antibiotic
Committee and the Infection Control Committee should receive regular
updates on antibiotic susceptibility of bacterial isolates from the
local area. This will assist the Committees in producing effective
guidance for the local patient population. The laboratory should also
alert the Committees to the emergence of widespread resistance to
certain agents so that the inclusion of those agents in the guidelines
can be reviewed.
An effective antibiotic policy also provides
and ensures education on the use of antibiotics at undergraduate and
postgraduate level for medical and nursing staff.
In a fast moving city like Mumbai, health care is a booming business and the competition is fierce and sometimes cut-throat,
People
want the best possible care at the most competitive prices. It is,
therefore, imperative for health care providers to be aware of the
latest trends in the health care segment. One needs to innovate and
improvise to go ahead in the rat race.
Facilities are seeking to
reduce hospital-acquired infections, particularly as reimbursement for
these events is being eliminated. Materials using nanotechnology and
silver-ion treatments that destroy bacteria are promising advances in
this area.
Single patient rooms, one of the most significant
health care design developments of recent years, are believed to improve
patient safety by reducing the chance of infection and promoting family
involvement in patient care.
Since a patient can remain in a
universal room even when his or her condition changes, this too is
expected to be shown a safer, more comfortable design for patients and
their families.
Future technological developments will continue
to have a major impact on design. As technology advances and new care
models emerge, it will be increasingly important for architects and
interior designers to be specialized in the needs of health care.
Technological advances also have a clear impact on health care engineering and information systems
Development
of Integrated Electronic Medical Records will help physicians make
better, faster decisions. And it will assist in public health efforts,
making it easy to identify and contact, for example, patients who were
prescribed a certain drug.
RFID
Radio-frequency
identification (RFID) as an important part of such data-gathering
systems because RFID tags can collect information automatically without
giving busy hospital staff another task to complete.
Hospital
environments are going to be created around the patient, rather than the
patient being taken to specific locations for services. This will
entail rooms with “substantially more intense” infrastructure systems,
along with the engineering design challenge of turning those systems on
and off as needed.
Infection control measures are being tested by
the emergence of multi drug resistant organisms. Surfaces that are
resistant to bacteria growth will help in this area. So will better
tests for cleanliness, such as meters that can measure bacteria in parts
per million.
Integrated tech systems
Designing
integrated technology systems will result in enhanced patient care.
Technology applications are no longer self-contained silos. In the past,
we installed individual applications, such as pharmacy, lab and
radiology. Today, we track the information flow from one system or
application to another to know how the care team will use that data.
Such collaboration by the IT staff will continue on all aspects of the
systems development life cycle, from identification of needs to
post-implementation needs.
Technology will be used to develop
best practices in quality patient care. Knowledge is indeed power and
hospitals will continue to use information to demonstrate that the
expectations of quality and safe care are being.
Technology will
become a positive enabler of high-quality patient care with electronic
medical record implementation becoming a strategic goal at more health
care organizations.
There would be expanded patient involvement
at the hospital point-of-care as consumers take a more active role in
their own health care management through patient portals and other
interactive Web-based tools.
So we have hospitals offering
anything from internet kiosks for cyber surfing to plasma LEDs for some
real entertainment. The idea is to offer the latest in the business,
what your competitors don’t. Some of the suites of hospitals offer
better services than five-star hotels.
The need of the hour is to
offer world class care and the latest technology at competitive rates.
With the advent of medical tourism it is imperative for hospitals to get
accreditation. This will be possible only through strict quality
control and rigorous training. Web-site development and other services
could help the hospital make a name for itself at national and
international arenas.
A pro-active management coupled with a
positive approach can play a major role in establishing a world class
centre of excellence.
Futuristic hospitals could entail use of
robotic surgeries, genetic studies and treatment based on genomic
mapping, executive fitness programmes,day care surgeries, sports
medicine and computer based treatment regimens.
(Author is senior medical superintendent of Bhatia Hospital, Mumbai)