Emergency Medical Services

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    Performance Audit on Arogya Kavacha 108 Project in Karnataka (2014-2019)
    (CAG of India, 09-12-2020) CAG of India
    Emergency medical services (EMS) is defined as the system that organises all aspects of care provided to patients in the pre-hospital or out-of-hospital environment. It is a critical component of health systems and is necessary for improving outcomes of injuries and other time-sensitive illnesses. Government of Karnataka aimed to provide a comprehensive Emergency Response Service, from the time of event occurrence to shifting to an appropriate hospital, through a single toll free number ‘108’ for which, it had entered into a Public Private Partnership arrangement (Design, Build, Operate and Maintain model) with GVK Emergency Management Research Institute, Secunderabad through a Memorandum of Understanding (MOU). The success of EMS is largely dependent on its responsiveness to emergencies and the adequacy of the infrastructure in place. The performance audit conducted for the period 2014-15 to 2018-19 intended to ascertain whether EMS was appropriately responsive and equipped to deliver quality pre-hospital emergency care and the Information and Communication Technology deployed in the project was supporting the overall activities and the objective of delivering quality emergency care adequately. Though the project envisaged catering to police, fire and medical emergencies, 99 per cent of the emergencies attended to were medical emergencies. Audit noticed that EMS fell short of achieving the desired objectives completely. The project aimed to reach the patients/sites within 20 minutes on an average in urban areas and 30 minutes on an average in rural areas. However, rural-urban classification of data was not available. Hence, maximum 30 minutes’ response time was considered for audit analysis and we noticed that this was achieved in only 72 per cent of the cases. The response time comprised triage time, chute time and travel time. The triage time was more than the stipulated three minutes in 47 per cent of the cases. In 85 per cent cases, the chute time was more than the stipulated one minute and was up to 100 minutes and beyond in few cases. Studies indicate that the response time for cardiac, respiratory and stroke cases was to be less than 10 minutes. However, the ambulances reached the patients after the stipulated 10 minutes in 62, 66 and 63 per cent cases respectively. In 50 per cent of the trauma cases, the patients were admitted to the hospital after the crucial one-hour time. In the absence of adequate follow-up data, the impact on the final outcome of the patients could not be ascertained. The total calls received comprised 64 per cent ineffective calls, out of which no response and disconnected calls were 42 and 34 per cent respectively. The callers were called back only in three per cent of the disconnected cases indicating absence of call monitoring mechanism. Pre-arrival instruction is a critical component in EMS. There was no mechanism in place for alerting the hospitals in advance about arrival of ambulances. In 18 per cent of the cases, there was a delay in handing over the patients beyond 15 minutes because of which 1.75 lakh ambulance hours were lost. This was compounded by the delay in reporting closure of cases by the crew even after reaching the base station leading to loss of 31.87 lakh ambulance hours. Ambulances were despatched only in 3.74 lakh cases out of the 8.87 lakh requests transferred to vehicle busy desk. The allocation of ambulances was not based on criticality of emergencies as ambulances with Basic Life Support system were allocated in 75 per cent of the cases to critical emergencies such as cardiac, respiratory and trauma that required allocation of Advanced Life Support systems. The project adopted population as the criteria for deployment of ambulances. In the absence of policy regarding positioning/location of the ambulances, we observed that ambulances were stationed mainly within the Government hospital premises and not within the vicinity of black spots. The round trips undertaken by the ambulances impacts the responsiveness of EMS. There were 20 and 21 per cent vacancies in the post of ambulance drivers and emergency management technicians respectively. The shortage of ambulance staff led to ambulances remaining off the road for 41,342 days during the audit period. Emergency Response Centre Physicians (ERCPs) were required to provide virtual medical directions to EMTs who were in the field. There were only three ERCPs available at the emergency response centre. The percentage of unanswered calls by ERCPs was 58.20 and 65.52 during 2017-18 and 2018-19. There was no strategic management plan to ensure the availability of EMS to disadvantaged sections such as people living in remote/tribal areas, marine fishermen etc. In addition, assessment of effective response time for different categories of emergencies, pre-alerting mechanism, monitoring of patient outcomes, upgradation of ICT infrastructure and research of effectiveness of pre-hospital care remained out of the purview of the top management at Government level. Validation procedures were absent which resulted in incomplete data, back-end insertion of data and incorrect reporting. Back up plans, incident management and business continuity plans that were necessary for taking remedial measures in cases of disruption were not prepared. There were no reporting arrangements between the Government and the Partner. There were 6,411 complaints received from emergency service users during the audit period. However, the Government was not informed of the public grievances by the Partner in the absence of any such mechanism. The State Government did not have access to project databases, which impaired monitoring of the project and the use of data to undertake research and development activities for improving patient care. The State and District level committees, which were supposed to monitor the project were not constituted. The Government decided to discontinue the association with the Partner before the scheduled 10-year period citing deficiencies in services. However, the existing service provider is continuing as identifying a replacement partner was delayed. The MOU did not provide for an exit strategy plan for fulfilment of the contractual obligations as regards transfer of assets and intellectual property rights. The consequent risk of disruption in implementation of the project could not be ruled out. The project was also not evaluated despite being in operation for over a decade.