Covid patients reached the hospital on time but the hospital’s mismanagement killed them
The government’s failure to manage equipment and medical workforce spiked the death rates.
July 29, 2021 – Rita Lamsal
Case-1
A 38-year-old man was taken to Charikot Hospital for treatment of a respiratory problem on May 23. An antigen test showed he was covid infected. An x-ray report diagnosed him with pneumonia with his lever badly damaged. Doctors in the hospital referred him to admit him to an ICU immediately but the district lacked special services for the treatment. Covid patients with other serious health problems needed a high-flow oxygen facility that is only available in ICUs which have ventilators and high dependency unit (HDU)facilities.
He was then airlifted to Kathmandu’s Everest Hospital for his treatment but it was late. He took his last breath during his treatment at ICU seven days later. “We took him to an ICU in Kathmandu by helicopter but unfortunately we could not save him,” a relative of the covid victim lamented to Swasthya Khabar. He wished that he could have been saved had there been an ICU at Charikot.
Case -2
A 42-year-old resident of Myagdi Municipality-5 had a fever, cough, and chest ache. Thereafter his stomach was swollen as well as serious respiratory problems. He was taken to Beni District Hospital on May 11. He tested covid positive and an x-ray report showed a lever problem. His health worsened with the common oxygen support, which was only available in the district.
The only 5-bed hospital has had an ICU with essential equipment, but it’s gathering dust because there is no workforce to operate the ICU. The doctors referred him to other hospitals which have ICUs but the poor family could not afford ambulances and other costs. The person died the other day.
The son of the deceased father told us, “We made a lot of efforts to take him to a hospital with ICU services and had also talked with the chairman of the Beni Hospital but he took his last breath amid confusion and delays.”
The person was not alone to lose his life without access to essential ICUs amid the fatal second wave of the covid. According to the medical superintendent of the Beni Hospital Dr. Jitendra Kandel, many other covid positive patients have succumbed to death simply because the nearest district hospitals have no services in operation. The ICU at the Hospital was established a year ago but the lack of specialist doctors, mainly anesthesiologists and paramedics, was the main reason behind the loss of lives, according to the hospital.
More patients were referred to cities as districts hospitals lacked the essential service
These two patients of Dolakha and Myagdi are textbook examples of how covid patients died in the district hospitals without treatment because of a lack of ICUs facilities or specialist doctors to operate them. Although some district hospitals have manpower but lack the ICU infrastructure. The hospitals in Kathmandu and other major cities are overwhelmed with covid patients because of the mismanagement of manpower and ICU facilities in the districts. The district hospitals are understaffed and lack essential equipment and services because of the federal government’s apathy.
Bheri Hospital of Nepalgunj, Bharatpur Hospital, Chitwan, Chitwan Medical College, College of Medical Sciences, Lumbini Provincial Hospital, Paschimanchal Hospital Pokhara, Nobel Medical College Biratnagar, and Koshi Hospital have seen an overwhelming number of referred covid patients from the nearby districts. Key hospitals like BP Koirala Institute of Health Sciences (BPKIHS), Seti Hospital of Dhangadhi, Shukra Raj Tropical and Infectious Disease Hospital, Teku, Tribhuvan University Teaching Hospital, Bir Hospital, Patan Hospital, Armed Police and Army Hospitals have seen more than expected referred covid patients according to hospital administrators. The case of private hospitals in the capital city and urban centers is also the same.
On this issue, the administrators have commonly stated, “Had there been skilled manpower and equipment in each district hospital, more lives could have been saved as so many referrals would have been avoided and those referred would not succumb to coronavirus on the way following the referral.”
Most of the covid patients took their last breath at the hospitals
As of Mid-June, 8,506 people have lost their lives due to Covid-19 across the country. Data analysis of the Covid death by the Center for Data Journalism Nepal (CDJN) till mid-June found that 92 percent died in hospitals. Only five percent lost their lives at home (428), while less than one percent lost their lives on the way to the hospital (57) and at isolation centers (44), according to the analysis of the open data of covid deaths prepared by the Ministry of Health and Population. The other 32 people died in the quarantine facilities It’s not known where exactly 71 covid patients died according to the ministry data.
Many Covid patients succumbed to coronavirus though they had reached the hospitals on time because the hospitals had poor infrastructure or lacked specialist doctors to operate in the ICU or both. Dr. Subash Acharya, in charge of the intensive care unit at TU Teaching Hospital, says, “The number of ICUs and ventilators is negligible proportion to the population we serve, and the available human resources to operate them is far less.”
Data analysis of covid death composition says that 57 percent took their last breath in hospitals other than Kathmandu Valley or mostly in the district hospitals. The remaining 43 percent of the deaths took place in the different hospitals of Kathmandu, Lalitpur, and Bhaktapur. As many as 531 covid deaths, the largest number by hospitals, were reported in Bheri Hospital, Nepalgunj.
Covid deaths at hospitals– Tribhuvan University Teaching Hospital, Patan Hospital, Lalitpur, and Chitwan Medical College, Chitwan– were 432, 326, and 317 respectively. Likewise, 281 people succumbed to coronavirus at Biratnagar-based Nobel Medical College followed by Lumbini Provincial Hospital with a casualty of 254. The death toll at the BPKIHS was 244 while 239 and 188 people died at Nepal Army Hospital and Seti Provincial Hospital respectively. A total of 632 succumbed to coronavirus without reaching the hospital.
Govt’s apathy behind the lack of equipment and manpower crunch
There were only 984 ICUs and 490 ventilators in the country before the first wave of covid came in, according to health infrastructure statistics of the Ministry of Health and Population (MoHP).
Amid covid, both the government and private sector hospitals added health infrastructure. Till mid-May, new 3,846 High Dependency Units(HDU), 1,767 ICUs, and 625 ventilators were installed focused on the treatment of the covid patient. Most hospitals didn’t have HDUs before Covid, according to the MoHP.
The new infrastructure was installed by the provincial Health Emergency Operation Centers (HEOC) in coordination with the concerned hospitals, according to the records maintained by the ministerial HEOC. In addition to these, even local-level hospitals may have established such infrastructures but HEOC has no record of such infrastructures, according to the assistant spokesperson of the ministry Dr. Samir Kumar Adhikari.
But the statistics of these essential infrastructures, particularly important for the treatment of Covid patients, vary due to the lack of proper reporting of such infrastructure by the private hospitals.
The government has also failed to manage the essential manpower to operate this equipment when many succumbed to coronavirus without getting oxygen support at ICUs. Leadership in the Ministry of Health and Population is clueless about the number of working manpower at public and private hospitals to operate this infrastructure. The government is also not aware of the status of the existing infrastructure as well.
Dr. Adhikari tried to come clean saying that the majority of the health sector workforce is now managed by the provincial and local governments after the federal set-up and therefore the federal government is not responsible for this. The officials at the MoHP have blamed the local and provincial governments for not providing data to the Singhadurbar.
“We don’t know exactly where the medical workforce has been deputed and is working and the status of the shortage of manpower,” said Adhikari. Adhikari also acknowledged that they have challenges in the management of the medical manpower in absence of the integrated statistics.
Subash Acharya, ICU in-charge at TUTH, said that each ICU must have a nurse, medical officer or resident doctor, and specialist doctors (Anesthesiologists) based on the number of patients round the clock. Every 10 patients require at least an anesthesiologist. The ICU of Level-3 also requires a critical care physician as well. “But it’s a bitter truth that most of the ICU units across the country don’t have these critical workforces,” said Acharya.
Nurses should have got an additional three-month-long training in critical care to attend to the patients in ICUs and ventilators. The country now needs about 14,000 nurses with critical care training qualifications for attending to patients at the 2751 ICUs but such working manpower is too low. General secretary of the Critical Care Nurses Association of Nepal Kabita Sitaula said that they do not know how many nurses have so far been trained in critical care. “Even the nursing council has not prepared a separate list of nurses with critical care skills, but this is important for improving the services,” said Situala.
Former expert at the MoHP Dr. Sushil Nath Pyakurel emphasized proper management of the manpower in critical care. “Otherwise, fatalities may repeat as in the second wave if no emphasis is given on recruiting more health workers as required. Equipment alone can not treat patients,” added Pyakurel. Pyakurel has suggested the ministry collect integrated data of all health workforce first and start managing the health workers as per need.
This report was prepared with support from the Center for Investigative Journalism, based in UK. The original version of this story was published in Swasthya Khabar. Click here to read the story.
