States are adding hospital beds, but are there enough doctors and nurses?

Bihar already has a shortage of nurses, Chhattisgarh has a shortage of doctors. Many other states might not have resources if active cases double

A pivotal highlight of Maharashtra Chief Minister Uddhav Thackeray’s last month’s public address—the state has since imposed a lockdown—was cautioning people that even if the state does add more beds, ventilators and ICUs, constraints like human capital cannot be addressed in the short-run.

Last year, Mumbai had to source doctors and nurses from Kerala to get the situation under control. Many other states had to draft fourth- and fifth-year medical students to address the rising cases. The crisis this year is no different. Some hospitals are actively looking for nurses to man their Coronavirus (Covid-19) wards.

“We are discussing the recruitment of more nurses for our Covid wards. The situation is grim, and all the medical staff is overworked and exhausted,” said Jessica D’Souza, chief nursing officer, Global Hospitals, Mumbai.

Since daily cases have crossed 250,000, the focus of states has been on getting oxygen supplies and ensuring that there are enough beds available. However, not much attention is being paid to the availability of medical personnel. Most hospital staff is working overtime, tending to patients. A Business Standard analysis shows that if cases were to keep rising, some states might not have the requisite workforce to deal with the growing Covid-19 crisis.

Let’s start with Delhi. The Minister of State (Health) in Rajya Sabha last year highlighted that the city might have 21,348 registered allopathic doctors. Assuming that 40% are serving corona infected patients in hospitals, Delhi would have a maximum of 8,539 doctors in service for Covid-19.

Delhi has 94,592 active cases, of which nearly 20% require hospitalisation and 5% require an ICU. The data on ventilator beds is not available, but we assume that ventilator bed requirements are half of the ICU bed requirement. A fortnight ago, when the government was releasing ventilator data, the number of ventilator beds available was nearly half of the total ICU bed availability.

If that were the case, then the city would need 4,651 nurses and 1,959 doctors in each shift. This data is derived based on conversations with hospitals across the country.

“As of this movement, the ratio of nurses to ventilator beds is 1:2, and the ratio of nurses to ICU beds is 1:3. Although the norms prescribe a 1:1 ratio for ventilators and 1:2 for ICUs, these are unprecedented times,” D’Souza iterated.

In Covid wards, one nurse caters to 10 patients. Similarly, one doctor caters to 7 patients on ICU beds. And it takes one doctor to look after 20 patients in a Covid ward. While nurses work in three shifts, doctors work in two.

“The reason we are working nurses in Covid ward in three shifts is because we do not want our nurses to get exhausted and overworked; we need them on the job,” says Dr Vivek Talaulikar, CEO, Global Hospitals.

Delhi would be comfortable if nurses work three shifts and doctors work two shifts even if cases double in the capital. Analysis shows that the city would still have 8% of its currently serving doctors and 45% of its nurse staff available.

However, if hospitals were to adhere to NABH guidelines released in 2005, the city would start running out of nurses once cases go up by 50%. If cases double, it would not even have the requisite number of doctors to deal with the situation and may have to commission others for Covid-19 work.

But not all states have as many doctors and nurses available on call.

While many state governments and the central government do not release data on hospitalisations, country-wise averages put the average hospitalisation rate at 20% and the ventilator and ICU bed requirement at 1.25% and 2% of the active cases, respectively.

Based on our analysis, Bihar, Jharkhand and Uttarakhand may be putting more stress on their medical staff, given the paucity of medical professionals. According to our analysis, Bihar needs 30% more nurses, whereas Jharkhand and Uttarakhand require 34% and 5% more registered nurses, respectively. For clarity, our analysis does not include auxiliary nurses and lady health visitors. It also does not account for the migration of nurses to other states. If we add auxiliary nurses, nearly all the states sail quite comfortably.

In terms of doctors, Chattisgarh needs 13% more doctors, at present, aaccording to our analysis. Now, if active infections in all the states were to increase by 50%, Telangana would have a shortage of 14% in doctors and may have to ask other specialists to serve as Covid staff. 

And, in the scenario where active infections double across the state, even Maharashtra may fall short of registered nurses.

Can resources be shifted from one state to another, as it happened in the first wave? Dr Alok Roy, chair,  FICCI health services committee and chairman Medica Group of hospitals, says that the country will sail through. “We have an overworked and exhausted medical staff, but we can cater to rising cases,” he told Business Standard. 

But D’Souza and Dr Talaulikar highlight that fault lines have started appearing. “All our network hospitals have staff that is working overtime to get the situation under control. If all states have this problem, then getting staff from another state may not be so easy,” they note.

The analysis does not consider the shortage of intensivists in hospitals and shortages arising in particular cities. For instance, Maharashtra may sail through comfortably, but would Pune have enough staff?. This granular data is not available. An analysis by Covid Task Force in Karnataka last year had said that for round-the-clock coverage of ICUs in Bengaluru, 2,800 nurses, 800 resident doctors, and 400 anaesthetists would be needed to cover 2,000 beds. It had estimated that Bengaluru would need to touch 16,000 active infections to require this infrastructure. Active cases in the city today are 24,600.