Central team questions Bihar doctors’ treatment plan for AES
The central team, which reached Muzaffarpur on June 12, has punched holes in the treatment plan and diagnostic work-up being followed by doctors at SKMCH.Updated: Jun 21, 2019, 14:43 IST
The seven-member central team that recently visited Muzaffarpur, the epicentre of acute encephalitis syndrome (AES), has raised serious doubts over the competence of the medical and nursing staff managing such child patients in Bihar hospitals.
Most of the children are being treated at the state-run Sri Krishna Medical College and Hospital (SKMCH) or the trust-run Krishnadevi Deviprasad Kejriwal Maternity Hospital (popularly known as Kejriwal maternity clinic) in Muzaffarpur. The mystery disease, whose causative factor remains unknown and affects the brain of children, has claimed 135 lives against 623 cases reported across Bihar so far this year, even as unconfirmed reports put the AES death toll at 151 in the state.
The central team, which reached Muzaffarpur on June 12, has punched holes in the treatment plan and diagnostic work-up being followed by doctors at SKMCH. The team observed that no effort was being made to rule out various causes of encephalopathy or encephalitis in children with AES, according to the agenda points for discussion prepared by the central team with senior state health officers. Hindustan Times has a copy of it.
“Antigen-based rapid diagnostic test or microslide for malaria parasite is mentioned as mandatory at PHC (primary health centre) level. However, it was not done in any children even at the medical college level,” it said.
“Other important diagnostic work-up, including arterial blood gases (ABG) or venous blood gases (VBG) test (it measures the acidity, or pH, and levels of oxygen and carbon dioxide from an artery to check the functioning of a patient's lungs) were not available in any of the cases (the team had examined all AES patients — 50-and-odd admitted at the SKMCH on June 13),” it added.
The synopsis, which formed part of the central team’s report, said that cerebral spinal fluid (CSF) examination was also not available in any of the cases examined, while neuroimaging was available in only one case.
Commenting on treatment plan, it noted, “The standard operating procedure (SOP) describes protocol for empirical therapy in form Ceftriaxone (injection), Artesunate and Acylovir. All children received Ceftriaxone injection but none of them received Artesunate or Acylovir.”
The report mentioned that a clinical team from the All-India Institute of Medical Sciences (AIIMS), Patna, made efforts to orient nurses and doctors on care plans of raised intracranial pressure (pressure inside human skull), care of unconscious child, management of status epilepticus, management of hypoglycaemia, and providing cardio-pulmonary resuscitation (CPR).
The central team also observed that some essential drugs, mentioned in the SOP, were not available at the Sadar hospital or medical college hospital. However, it said that the SKMCH superintendent’s office promptly procured the essential drugs and consumables that were not available.
On hospital infrastructure and availability of human resources, the team was highly critical on the composition of paediatric intensive care units (PICUs). “Areas labelled as PICU do not fulfill criteria to be labelled as PICU on multiple standards, including space, functionality of equipment available, number of doctors and nurses, documentation, record-keeping and training and competency of medical and nursing staff,” it said.
It also made a reference to the lack of magnetic resonance imaging (MRI) facility at SKMCH that could have been beneficial in management and research of AES. Moreover, it noted deviation from SOP for AES despite the state government conducting continuous training programme for health staff in the state.
The agenda points said in conclusion, “Preparedness in endemic area and especially in medical college at Muzaffarpur should have been more robust to face this (the challenge posed by AES)… Additional manpower should be deployed from other medical colleges to control the situation… Authorities should also ensure onsite training of all cadres of medical staff (professor to intern) and nursing staff to ensure better compliance of SOP.”
Bihar principal secretary, health, Sanjay Kumar said, “Based on the feedback of the central team, we have already taken action and redeployed at least nine senior residents from different medical colleges to SKMCH. We are also in the process of upgrading the PICU into a composite 100-bed unit. Though we have been conducting regular training programme of doctors and nurses, we will consider conducting short-term refresher course on SOP for AES from next year.”
He added, “We are in the process of installing MRI at SKMCH. It should be commissioned hopefully in the next 10-15 days.”
The seven-member central team was headed by senior paediatrician Dr Arun Singh, who is also the national adviser of the Rashtriya Bal Swasthya Karyakram of the ministry of health and family welfare.