Feature story

Critical change

A telemedicine-based model of emergency care is saving lives and cutting costs while catering to more than 1 million people in six districts of Telangana

Boddu Laxmirajam had suffered serious internal injuries after a heavy fall while working in his field. Semiconscious and battling for life, he was wheeled into the emergency-care facility at the district hospital in Sircilla in Telangana. All that stood between the 45-year-old Mr Laxmirajam and the possibility of death or permanent disability was a slender 30-minute window of critical care.

Acting swiftly, the doctors at the hospital performed an initial investigation, followed by an MRI (magnetic resonance imaging) scan that was guided by a neurologist at the Nizam’s Institute of Medical Sciences (NIMS) in Hyderabad, 140km away. Based on the diagnosis, the doctors at the district hospital performed a thrombolysis procedure to break down the blood clots putting Mr Laxmirajam’s life in danger. The four-hour operation was a success and Mr Laxmirajam was saved. “I felt hopeless initially but the doctors came to my father’s rescue,” says Mr Laxmirajam's son, Chandu.

The crucial role in getting Mr Laxmirajam out of harm’s way was played by the Tata Trusts-supported emergency intensive care unit (eICU) programme launched in Telangana and being piloted at the Sircilla district hospital. Mr Laxmirajam is one of more than 4,500 patients to receive care under the initiative, which aims to improve critical health services in the state’s rural regions.

Timely treatment

When 40-year-old Molluguru Anjaiah lost consciousness due to hyperglycaemia, fever and an infected foot, he was rushed to the government hospital in Zaheerabad in Telangana’s Sangareddy district. Had it not been for the short distance to the hospital and the swift action of the doctors on duty there, Mr Anjaiah would likely have lost his leg.

Mr Anjaiah’s condition put him at grave risk of brain damage from cerebral hypoxia (lack of oxygen supply to the brain) and sepsis caused by infection. These risks were dealt with thanks to the timely care he received at the Zaheerabad hospital, which is a part of the Tata Trusts-supported telemedicine-based emergency intensive care unit (eICU) network.

Mr Anjaiah’s doctors counselled him and his family on the prognosis of his illness and necessary post-hospital care. “I am genuinely grateful for the tremendous efforts of the team to improve my health and wellbeing,” he says.

Many critical-care patients in Sangareddy district have benefitted from the eICU programme. They get high-quality medical care and no longer have to travel far for treatment. The model has transformed the Zaheerabad hospital, says ICU specialist Nithin Kumar Jangam, and it has built up the confidence level of the staff there. “Earlier, we would refer all critical cases to other government hospitals,” he says. “With the setting up of the eICU, the referral rate has decreased by 80-90%.”

The Trusts provide techno-managerial support to the eICU initiative, which is backed by the Government of Telangana in collaboration with NIMS and the National Health Mission (NHM). Launched in 2021, the eICU programme covers eight peripheral hospitals with 64 ICU beds and caters to a population of nearly a million-plus people living in 88 villages in six districts.

High-quality attention

Besides being a life-saver for poor patients, the initiative has helped improve healthcare delivery in outlying areas by enabling access to specialty care and high-quality medical expertise. “Earlier, critical cases would be referred to tertiary-care hospitals in urban areas; this would delay treatment,” says Sita Rama Budaraju, senior consultant, health, with the Trusts. “eICU has enabled peripheral hospitals to consult specialised doctors immediately, saving precious time.”

The need for such an effort was acute. Telangana is one of India’s fastest-growing states but parts of its rural healthcare landscape are barren, especially lacking in specialised and ICU facilities. Patients have to travel long distances to urban centres for treatment and critically ill patients would often miss the ‘golden hour’ window for medical care.

The eICU programme is designed to bridge this gap in emergency care. The model uses telemedicine to provide specialty expertise to patients in peripheral areas, reducing the need for long-distance travel and improving treatment outcomes. The programme also addresses the shortage of trained staff in peripheral facilities through 24/7 consultation via its platform.

At the heart of the eICU’s approach is a hub-and-spoke model. The central hub at NIMS acts as the eICU command centre to support peripheral hospitals, which are the spokes. The hub has a dedicated team of consultants, senior residents, nursing staff and data-entry operators to deliver multidisciplinary support. The peripheral facilities, the ‘first line of treatment’ for patients, are strategically chosen, based on their infrastructure and proximity to the nearest tertiary-care centre.

Technology plays a vital role in the eICU model and that’s where the Trusts come in. Doctors at the hub and the spokes are connected by video conferencing technology that facilitates real-time patient evaluation. To allow the NIMS team to monitor patients remotely, pan-tilt-zoom cameras have been installed at each ICU bed. The model uses Medintegra software, customised as per the eICU communication protocol to ensure efficient data entry and management.

Training way

The success of eICU is dependent on the capacity building of health workers. NIMS has developed tailor-made training programmes to upgrade the knowledge of personnel at rural ICUs. ‘Peripheral ICU upgradation and integration’ training is conducted regularly to provide staff with insights into typical procedures such as tracheal intubation, cardiopulmonary resuscitation and central venous catheter placement. The training is reinforced through knowledge-sharing sessions and continuous medical education programmes conducted by the doctors at the hub.

Nitesh Kabra, a faculty member at the eICU hub in NIMS, says that the support of the state government and the Trusts has amplified the efforts of the doctors, nursing staff and technicians working at the hub. “It is a collaborative effort and a learning experience for the doctors at the spokes as well as here,” he says.

Given eICU's ambitious scale, its implementation was not without its share of obstacles. The first was getting a buy-in from the healthcare personnel at the spokes. They had to be persuaded to participate in the programme and accept the support provided by doctors at the hub.

The eICU team at NIMS during a video counselling session with a high-risk patient and his caregivers at the district hospital in Kamareddy

The second challenge stemmed from technological limitations. In the early stages, audio-visual aids proved to be unstable, hindering effective communication between the hub and spokes. However, alternative modes were quickly adopted to ensure seamless connectivity and information exchange. Quick and easy access to advice from specialist doctors helped tide over these initial hurdles.

Over the last two years, the eICU programme has produced strong results by making specialised healthcare accessible to patients in rural Telangana. Thousands of patients across the six districts covered under eICU can now access a higher level of medical expertise closer to home.

Patient families get financial benefits as well. Easier access to emergency health services locally means a lower burden of the hidden costs associated with illness, such as wage losses and travel and stay expenses. Another benefit of the programme has been the easing of patient loads on larger hospitals. Since eICU’s launch, patient referral rates from peripheral hospitals to tertiary hospitals have dropped significantly.

Additionally, the programme has helped improve utilisation of existing infrastructure at peripheral hospitals, which was low due to a dearth of trained staff. The model has also resulted in improved patient outcomes, with tertiary care centres reporting lower mortality and reduced length of stay.

The Telangana government is planning to upscale the eICU model to enhance its scope and reach. The intent is to establish 33 spokes, one in every district of the state, each with at least 300 ICU beds. Also in the pipeline is a strengthening of the hub by hiring more staff and upgrading infrastructure.

“We want to continue our knowledge exchange workshops and share upcoming research with the spokes. We want to bridge the healthcare gap in peripheral and rural areas,” says Dr Kabra. That means a further cascading of medical expertise from urban to non-urban areas of Telangana and making healthcare more accessible.