Anaesthesia and Chronic Pain

Anaesthesia Practice in Nursing Homes

Hemant Shinde

Introduction
Nursing homes have a very significant
place in Indian healthcare. Over the years healthcare in India has passed out of the hands of the public sector into the hands of doctor entrepreneurs. The 60th National Sample Survey shows that the proportion of patients treated at the Government hospitals has declined from 60% in 1986 to 43% in 1995-1996 and to 39% in 2004-2005.
Current estimates indicate that at least 60-70% of healthcare services in India are provided by the private sector. The reasons for this change are many and range from economic growth of the country leading to higher disposable incomes and poor state of public hospitals, this has led to mushrooming of smaller and medium size nursing homes across the country. Lack of regulations, high profit margins, and huge demand for healthcare services has led to many doctors becoming an entrepreneur. Today a doctor or a corporate house can open a nursing home whenever and wherever they want, due to the lack of regulations, control or standards for hospitals in the country. To open a restaurant one needs twenty five clearances, but not many to open a nursing home.
These nursing homes are frequented by people in search of quality healthcare at a reasonable cost made available closer to the home of the patient. As the number of patients visiting nursing homes is increasing along with that even the number and complexity of surgeries conducted in the nursing homes is on the rise. This leads to multiple problems for the anaesthesiologist working in nursing homes.

Problems for Anaesthesiologist
Majority of problems for anaesthetist in nursing homes are because of lack of infrastructure. This happens because most of the times the ownership of the nursing home is in the hands of:
A non doctor businessman, doctors from non surgical specialties surgeon or a surgeon.
A non doctor businessman ‘Invests’ money in the nursing home and the sole aim is to achieve higher profits. Such owners have little medical knowledge and hence they do not understand medical problems. In such nursing homes after the initial investment is made very little profit is ploughed back in the infrastructure hence over the years maintenance of equipment and up gradation of machinery becomes a major problem. Also these nursing homes are open to many surgeons and anaesthesiologists hence many people are handling the same set of equipment so the wear and tear is much higher. anaesthesiologist working in such places must check the anaesthesia machine before starting a new case.
In the nursing homes owned by surgeons there are other set of problems. As the real estate costs are high in most of the mega cities a lot of money is required to buy a place. After the initial cost the surgeon requires additional investment for purchasing his own equipment hence when he wants to invest in anaesthesia machines the general tendency is to ‘cut corners’ and buy inexpensive machines. Many a times the anaesthesiologist is expected to invest in monitors and that too without recovering its cost from the patients.

Problems of Infrastructure
a) Lack of skilled help: Most of the nursing homes are working on minimal or just adequate staff. Unfortunately most Nursing Homes staff has no clue about anaesthesia procedures hence in the event of a ‘critical incidence’ no help is around for the anaesthesiologist. Anaesthesiologist working in such places must teach resuscitation Drills to the paramedical staff so that skilled help is around in the event of a complication.
b) Machines and monitors: It is mandatory to adhere to minimum monitoring standards when working in a nursing home. The need to upgrade or maintenance of machines and monitors must be told to the owners for the optimum safety of the patients. Most of the small and medium Nursing Homes do not have a Defibrillator as the cost of this equipment is high but in the event of a cardiac arrest it is this equipment that can resuscitate the heart. It is the duty of the anaesthsiologist to keep this machine in working condition all the time hence frequent checks are needed.
c) Drugs: In most of the Nursing Homes it is expected out of anaesthesiologist to purchase and use medicines required for anaesthesia. In such cases it is easier for the anaesthesiologist to check the stock and expiry dates. In those places where the drugs are purchased by nursing home and supplied to anaesthesiologist it is mandatory to check for expiry dates as well quantity of drug as sometimes shortages can occur Intra-operatively. Also it is important to check the stock of drugs required in resuscitation as shortages of these drugs can lead to disaster.
d) Electricity: As most of the states are facing power shortages and load shedding is becoming common everywhere it is mandatory to have invertors and generators to ensure uninterrupted electricity supply at least to operation theatre and intensive care units.

Solutions for these problems
At Government level serious thinking is required to bring a legislation which will determine the minimum standards for nursing homes according to the size and the number of beds. In U.S various accredition procedures are to be followed before starting a hospital. Various state governments can be asked to decide the minimum standards and medical associations can be given the duty of checking if nursing home is following these norms.
Role of Anaesthesiologist
Anaesthesiologist has a critical role especially in a nursing home. In most cases it is not possible for the anaesthesiologist to visit the patient prior to surgery. Hence there is no rapport between patient and Anaesthesiologist. Also condition of the patient is not known to him or her before operation so little planning is done. Many a times sudden problems are faced by anaesthesiologist prior to induction. A pre-op visit to the patient is hence mandatory. If he/she feels that a particular case should not be done in a nursing home it should be conveyed to the surgeon with reasons and should be deferred without any financial considerations. Normally ASA Grade I/II cases can be safely done in small nursing homes. Help of senior/experienced anaesthesiologist can be sought if difficulty is anticipated in any difficult case. It is better to do so at an earlier stage than last minute. Eternal vigilance is the key to success if one is working in a nursing home.

Conclusions
a) An anesthesiologist may be required to work in nursing homes as large amount of surgical work is done in nursing homes today. Anaesthesiologist should be aware of problems specific to smaller set up and how to offset them.
b) Government intervention in deciding minimum monitoring and service standards according to size of nursing home is necessary.
c) Eternal vigilance on the part of anaesthetist is essential and also keeping the anaesthesia technique simple is the key to success.
d) Remember that we all are working for the betterment of the patient; hence ‘First of all do no harm’. Safe anaesthesia is the best anaesthesia.