1. Christian Medical College: Accident & Emergency Care in Vellore, India
Elizabeth Lothamer, KUSON N4

2. Vellore, Tamil Nadu – India
Population - 484,690 (Census of India 2011)
Religious Breakdown of Vellore
70% Hindu
24% Muslim
5% Christian
Less than 1%
Buddhist
Sikh
Jain
Other
*Map of India with marker on Vellore

3. Background of Christian Medical College (CMC)
Founded by Ida S. Scudder
An American Missionary
Est – 1 bed clinic to serve women
1902 – grew to 40 bed clinic to serve women and children
Present Day - over 2,800 beds
(4x bigger than KU)
Accredited by the National Accreditation Board for Hospitals (NABH)
Non-government, private, interdenominational Christian organization
Serves people from all over India
*Ida S. Scudder,

4. Accident & Emergency Department
44 bed unit
Ratios
1 trauma bay (stable)
Bay 1-3: 10 beds
3 open bays
2 nurses & 1 doctor
Trauma Bay: 7 beds
For general emergencies
1 nurse for 4 patients. 2 doctors
1 resuscitation room
For all type one emergencies
Resuscitation Room
5-6 patients, 3 nurses, 2 doctors
Unstable
*Main entrance to emergency department

5. Accident & Emergency Clinical Objectives
Identify the main causes for emergency room visits at CMC and compare to those seen at The University of Kansas Health System (TUKHS)
Identify the treatment process of the emergent patient at CMC
Discover the flow of patients and how the system functions under stress
Determine safety hazards in terms of patient care and the solutions that are being done to reduce them
Identify costs associated with care and it’s impact on clinical decision making
*Crash cart located in the resuscitation room

6. Care of the Accident & Emergency Patient
Top 5 primary complaints
Trauma (two-wheeler accidents, pedestrian vs. auto)
Cardiac emergencies (HTN, CHF, rheumatic heart disease)
Asthma & COPD exacerbations (pollution)
Uncontrolled fever (typically GI or URI origin)
Severe anemia
Treatment Process
All patients are triaged upon arrival and receive an acuity rating
Level 1 – resuscitation room
First 4 hours of care are free of charge for these patients
Level 2 – bay 1 through 3
Level 3 – referred to outpatient clinic
Emergency staff is conscious to the cost of care – utilize clinical diagnosis and then support with investigation to reduce cost
Average cost of care is 3,000 rupees ($46 USD) – average income of CMC patient is 15,000 rupees a month ($231 USD)
Additional costs incur for pharmaceuticals, diagnostic testing, radiographic imaging, and procedures performed

7. Care of the Accident & Emergency Patient
Flow of Patients
pts/day
admitted
Consider a stay greater than 12 hours in bays 1 through 3 over-stays
greater than 4 hours in the resuscitation room
Bay average is 6 – 8 hours
Patient Safety and Delays of Care
Limited Emergency Medical Services – ambulances are for transport, not for emergent stabilization or resuscitation (witnessed two DOAs)
Infection control risk
Open units
Limited access for hand washing
Limited Resources
1 portable X-Ray, 1 ultrasound machine, 1 cat scanner.
Paper charting – information uploaded to computers after patient is discharged
Discussion with family on cost of care – pick and choose what they can afford
*Brought Dead Certificate

9. Interventions and Strategies to Reduce Emergencies
Individual
Increased access to primary care facilities
CONCH, CHAD, RHUSA
Utilization of public health nursing for primary prevention and education in the villages
Fever management, clean drinking water education, dietary habit analysis, etc.
Screenings provided in village clinics
HTN, anemia, diabetes, etc.
Community
Emergency Department will teach first aid management and injury prevention to schools, colleges, factories, businesses, and more.
CPR, fracture stabilization, emergency preparedness, etc.
Emergency medical services are very limited at the community level. Many patients self-present to the unit after trying home remedies.

10. Interventions and Strategies to Reduce Emergencies
System
The World Health Organization (WHO)
Currently working with government organizations in India to improve road safety
Current laws are in place but they are not widely enforced
“The Global status report on road safety 2013 estimates that more than 231,000 people are killed in road traffic crashes in India every year” (Kansla, 2017)  
WHO hopes to accomplish:
Increased road traffic violation fines
More strict helmet laws
Focus shift from communicable to non-communicable diseases
More government programs are being initiated to address the increase in non-communicable diseases like HTN, diabetes, etc.

11. *Blood pressure screening
*Family of 4 rides two-wheeler
*Blood pressure screening
*Busy morning commute
*Anemia screening

12. Conclusions & Suggestions
A large problem in India is overpopulation
Creates concern when it comes to health care resources
Must focus on primary prevention to ensure hospitals do not get over-run
When the Emergency Department starts to get over-ran the staff must rely on their team members and protocols in place in order to make things run smoothly
Suggestions
The emergency department needs to expand in order to accommodate the mass intake the hospital experiences (44 unit beds for 2,800 inpatient beds)
Increased staffing in order to make safer nurse: patient ratios
Updated equipment
Quicker cost analysis and management in order to reduce care delays

13. Most Profound Clinical Experience
A double edged sword
Staff maintains a diligent awareness to cost of care
One patient on admittance was pronounced brain dead
The team decided not to intubate
Would not be a noble use of the family’s money
Discharged the patient to home to pass away with family
Another patient on admittance had a skull fracture and was actively bleeding into his brain.
He had a 70% chance of making a livable recovery
Quality of life was unable to be determined.
Their was major delay in whether or not to perform surgery because of the discussion with family
After a significant amount of time had passed the family decided to pay for the surgery
Since it took hours to decide, the patients status had worsened and his odds of success were now worse
I saw the consideration of cost be therapeutic for one patient and detrimental for another, creating a double edged sword phenomena

14. Most Profound Cultural Experience
The people
I have never felt more welcomed in a foreign place
I could not speak the language but through gestures, touch, and smiles I was able to connect with the people in a profound way
Truly happy to invite us into their homes and wanted to share all they had
The hospitality of Vellore, India is something of true beauty that I will forever cherish
*Woman from the village of Melminnal
*Girl from the village daycare

15. References
Directorate of Census Operations Tamil Nadu (2011) Census of India District Census Handbook Vellore. 34, Retrieved from: CHB_VELLORE.pdf Vellore Christian Medical College Foundation, Inc. (2017) Humble yet bold beginnings. Christian Medical College. Retrieved from: World Health Organization (2017) Violence and injury prevention: road safety in India. World Health Organization. Retrieved from: rywork/ind/en/