Mumbai: Just after returning home, Prerna Kothari discovered tiny boils erupting on her otherwise healthy newborn’s skin.
The paediatrician at the nursing home where the child was born dismissed them as normal. Over the next two days, the boils turned to rashes, then into abscesses accompanied by high fever. The anguished parents turned to another paediatrician who told them that the infant had developed a serious infection and required immediate medical attention.
The baby was admitted to a speciality hospital, where tests revealed he had a “gram positive streptococcal infection, which could only have been contracted in a hospital setting,” said Kothari, who declined to name the hospital involved. “And he had never been to any hospital other than the one where he was born.”
The infection was so virulent that the baby had to stay in another hospital and surgery was required. The baby has recovered, but the mother is still seething over the birthing hospital’s failure to maintain a sterile environment.
She is hardly alone. While specific statistics for India do not exist, partly due to a lack of reporting by both patients and hospitals, experts estimate that more than 10% of patients admitted to hospitals here acquire infections in the medical settings.
Dismal conditions: Garbage littered by the side of the road leading to Hindu Rao Hospital from Malka Ganj, Delhi. Experts believe many health-care set-ups across the country may be falling short on many, if not all, of WHO’s guidelines governing patient safety. (Sanjeev Verma / HT)
According to a World Health Organization (WHO) report, health-care-associated infection affects millions of people worldwide and contributes to patient deaths and disability. It creates resistance to antibiotics and generates additional expenses to those already incurred by the patients’ underlying disease; WHO estimates that at any given time, more than 1.4 million people worldwide become seriously ill from such infections.
Between 5% and 10% of patients admitted to hospitals in developed countries acquire such infections, the report says. In some developing country settings, the proportion of patients affected can exceed 25%.
And medical observers largely agree that patient safety is cause for even more concern in India’s gargantuan and fragmented health care delivery system than the developed world.
“India is a big, diverse country. And while there are private, corporate hospitals which are state of the art, there are also many hospitals where the quality of care may be questionable and may even put patients in jeopardy,” says Dr Geeta Mehta, president of the Hospital Infection Society of India and head of the department of microbiology at the Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital in New Delhi.
Ironically, these health-care institutions are operating contrary to the fundamental principle of medical practice: Primum non nocere, or “First, do no harm.”
“Some Indian hospitals, especially public ones, provide the perfect setting for cross infection. They are crowded, they are filthy and they lack the equipment that is needed to create and maintain a sterile environment,” says Dr C. Gulhati, health-care commentator and editor of the journal, Monthly Index of Medical Specialities. “In fact, there have been instances where two patients have been forced to use one hospital bed. How can patient safety be assured in such situations?”
India has more than 700,000 hospital beds, and corporate hospitals account for only a small fraction of these. Many corporate hospitals insist they follow stringent patient safety norms. At Mumbai’s PD Hinduja National Hospital and Medical Research Centre, a special cell focusing on patient safety was created a few years ago. “There has to be a commitment at the institutional level as it calls for regular audits and attention to even the smallest of details. Many hospitals do not take up the exercise seriously because they might not like their mistakes to be notified,” says Dr Gustav Davar, medical director at the hospital.
Yet, resource-starved public hospitals are only part of the problem. The unregulated yet flourishing nursing home segment compounds it even further. Many of them do not follow WHO guidelines governing patient safety, which has recommendations on various aspects including blood safety, injection and immunization safety, safer clinical practices, and safe water, sanitation and health care waste management.
Experts believe many health-care set-ups across the country may be falling short on many, if not all, of these aspects. Blood safety, for instance, continues to remain a major concern. For every unit of blood transfused, a patient has an estimated 0.36% risk of contracting hepatitis B. In comparison, the risk for a patient in Japan is estimated to be about 0.000038%.
In cases of HIV, the National AIDS Control Organization’s countrywide report for 1998-99 indicated that approximately 7% of HIV-positive individuals were infected from a blood transfusion. Another study found that 72% of injections given in routine immunization were found to be unsafe, primarily because of reusing syringes and needles.
Hospital infection experts say the most basic and common cause of hospital infections—hand hygiene—is still not adequately addressed. “In some places you still find doctors and other staff using soap or diluted disinfectant solution between examinations. This itself is a major cause for infections and more people need to be aware that it is imperative to switch to alcohol-based hand rubs,” says Mehta of the Hospital Infection Society of India.
“Adverse events on patient safety often go unreported so we never know the extent to which it is happening. If statistics show that patient safety is a concern even in the developed world, what can be said about surgeries that happen at district hospitals in the heart of rural India?” asks an expert with one of the United Nations agencies, declining to be identified citing policies on who can speak to the press.
In rural India, patients can be even worse off because in the absence of medical facilities and trained medical staff, they are often given bad—or dangerous—advice, said Dr Abhay Bang, a public health expert and founder of the Society for Education, Action and Research in Community Health.
Even doctors who have been trained sometime resort to practices that are not acceptable.
“We found that 30% of women who opt for home deliveries seek the advice of a private practitioner,” he said, referring to a study. “And almost all these private practitioners often use labour inducing drugs even when it is not needed— increasing the risk of uterine rupture or damage to the baby,” says Bang.
He adds that patients in rural India are also needlessly administered intravenous infusions of saline or glucose. “This practice can cause more harm than good.”
In case the patient has to go to a district hospital, he also runs the risk of being exposed to cross-infection.
The Union government took cognizance of the issue of patient safety a few years ago. In 2006, it committed to address health-care-associated infection in the country by pledging support to the Global Patient Safety Challenge, an initiative that seeks to reduce the risk to patients receiving health care. In India, the initiative was to focus on public hospitals. Officials working with the ministry of health and family welfare, however, say the initiative has made little progress.
“There is an acceptance of the issue and there is an increase in awareness and there is a willingness to do something about it, but that is just about all the progress that we have made,” says an official, speaking on the condition of anonymity.
Any tangible impact on patient safety standards in the country requires not just willingness, observers say, but significant introduction and implementation of safety standards. More training is required, as well as the inclusion of patient safety as a mandatory part of medical and nursing curricula.
“But more importantly, we have to develop our own solutions to some of these problems; solutions that are cost-effective and take into account the fact that ours is a largely resource-starved system,” Mehta says. “Clean hands is just one of them.”