“Caring for the Uncared for”: A Novel Initiative of Madras Medical College

Abstract

Background:

Every society has persons with illness who do not have any family support. Taking care of such uncared-for patients requires a well-structured system providing medical, psychological, emotional, and rehabilitory support. The first ever rehabilitation ward among government hospitals in Tamil Nadu was created at Rajiv Gandhi Government General Hospital (RGGGH), Chennai with the motto of “Caring for the uncared for.” This paper highlights the organizational structure, functionality, profile of patients admitted, challenges faced, and the outcome of patients admitted in the rehabilitation ward.

Methods:

A retrospective study was done on the “untended” patients, who were admitted in the rehabilitation ward at Rajiv Gandhi Government General Hospital (RGGGH), Chennai, Tamil Nadu, India from December 2020 to June 2022. Sociodemographic and clinical characteristics and outcome of the patients were analyzed.

Results:

A total of 201 adults with physical disabilities or mixed physical and psychiatric disabilities were admitted for intensive rehabilitation. Common medical illnesses included orthopedic disorders in 80 (39.8%), followed by neurological illness in 43 (21.4%) patients. The median length of stay was 50 (24.5-103.5) days with longest stay of 447 days. Of those patients who recovered, 54 patients (26.9%) reunited with family and returned home and 125 (62.2%) patients were sent to old age homes/asylums.

Conclusion:

A dedicated ward for untended patients is the first of its kind in the state of Tamil Nadu, India. Such a venture has proved to be of benefit, considering the positive outcome in a significant proportion of the beneficiaries.

Introduction

Untended patients with unknown identity are not uncommon in public hospitals.^1,2 The hospital receives untended patients whose true identity is unknown at the time of arrival at hospital, either because they do not carry identity documents or they are not able to identify themselves due to cognitive impairment. ³ Some of them are neglected by family and the others would have lost the way back after stepping out of home accidentally. Taking care of such patients poses medical, humanitarian, and legal challenges. There could be a myriad of physical and psychiatric issues in these patients. Hence, there is a felt need for a dedicated ward for providing holistic care for the untended patients. The rehabilitation ward at Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India was established on 3rd December 2020, for homeless and untended patients. Many such patients have diseases/disabilities that are so complex that multi-disciplinary care, sometimes including specialist in-patient care is required. This paper describes the experience of the designated ward for the management of untended patients with severe disability.

Materials and Methods

Rajiv Gandhi Government General Hospital (RGGGH) is the premier teaching hospital of Tamil Nadu state, affiliated to Madras Medical College, Chennai. This largest Government hospital of the state provides comprehensive specialist care free of charges for the underprivileged patients. The beneficiaries include patients from northern districts of Tamil Nadu and from adjoining states.

The designated rehabilitation ward comprises of 20 beds each for males and females (Figure 1). The facilities provided in the ward include hygienic balanced diet, drinking water, television, newspapers, refrigerator, water heater, laundry services, clothing and toiletries, and a garden with seating facility in the adjoining vicinity (Figure 2).

Figure 1.

Rehabilitation ward infrastructure.

Figure 2.

Rehabilitation ward facilities.

Functioning of the Rehabilitation Ward

The primary purpose of the ward is to provide individualized therapy aimed at optimizing health status of untended patients with physical or mixed physical and psychological disability. The untended patients brought by the ambulance/police personnel or other volunteers to the hospital are received at casualty and get admitted by the on-duty medical officer. At the time of admission all patients are clinically examined in the casualty department. Patients requiring surgical intervention and/or intensive specialist care, are referred to respective specialty departments immediately. After completing initial intensive specialized treatment, the patients will be transferred to the rehabilitation ward.

The rehabilitation ward is headed by a senior medical officer of the rank of Professor (Figure 3). The other personnel include junior medical officer, nursing staff, physiotherapist, nutritional therapist, social worker, and sanitary workers. Most patients admitted in the rehabilitation ward have significant and complex disabilities. Management plan for every patient is chalked out by the medical officer and specialist opinion is sought as and when needed. At admission, most patients would be unkempt with shabby dressing, poor personal hygiene, infested with head lice, ill-nourished, and with varying degrees of physical and cognitive impairment.

Figure 3.

Workforce hierarchy.

After thorough cleansing, the medical illnesses are identified and appropriate treatment is initiated. Nutritional needs are addressed and psychiatric evaluation is done by psychiatrist.

Patients with unruly and aggressive behavior are handled by skilled staff of psychiatric department. Nursing and other paramedical staff keep the patients constantly engaged in friendly and empathetic conversations and counseling.

When encountered with patients not knowing local language or English, Medical officers/nursing staff who can converse fluently in the language known to patients are posted temporarily. Though a balanced diet prepared in the hospital kitchen is regularly provided to all patients, special courses are also provided as per the choice/request of some patients. The wards are provided with television and newspapers.

A garden with pleasant greenery has been established adjoining the ward wherein the patients can sit, walk, and relax in the evening. Clothes are provided by the administration and a dedicated washing machine is provided for washing clothes. A barber is posted exclusively for this ward.

Data collection

Trained research personnel from Multidisciplinary Research Unit (MRU), Madras Medical College (MMC), Chennai extracted data from the Medical Records Department (MRD). Data included patient demographics, admission date, triage details, presenting complaints, length of stay, clinical details, and outcomes.

Outcome measures

The following outcomes were noted: (a) re-union with family, (b) discharge with stable health status, and (c) mortality.

Data analysis

Outcome data were analyzed descriptively in Statistical Package for the Social Sciences (SPSS) Software (version 1 5). Frequencies were used for categorical variables; and measures of central tendency (median and IQR) for continuous variables.

Results

During the study period, from December 2020 to May 2022, a total of 201 patients got benefited from the rehabilitation services. Table 1 presents the baseline socio-demographic and clinical characteristics of the patients. The median age of the patients was 60 (52-68) years including 149 (74.1%) men and 52 (25.9%) women. Of the 201 patients, 155 (77.1%) were in the age group of above 50 years. Most patients required longer period of admission, with a median stay of 50 (24.5-103.5) days. Six patients stayed for more than 300 days.

Table 1.

Sociodemographic and Clinical Characteristics of Patients.

Variables	Total N (%) &
Age <50 years	46 (22.9)
Age >50 years	155 (77.1)
Gender
Male	149 (74.1)
Female	52 (25.9)
Marital status
Married	82 (40.8)
Un-married	118 (58.7)
Divorced	1 (0.5)
Place
Chennai	138 (68.7)
Other districts of Tamil Nadu	46 (22.9)
Other states	10 (5)
Education
Graduation/more	7 (3.5)
High school	12 (6)
Middle school	5 (2.5)
Primary school	16 (8)
Illiterate	161 (80.1)
Number of Language known
1	184 (91.5)
2	12 (6)
3+	5 (2.5)
Job
Skilled	10 (5)
Unskilled	82 (40.8)
No job	109 (54.2)
Hypertension
Yes	17 (8.5)
No	184 (91.5)
Diabetes
Yes	26 (12.9)
No	175 (87.1)
Duration of hospital stay
Days #	50 (24.5-103.5)
Reasons for separation from family
Chronic physical disability	164 (81.6)
Alcohol addiction, chronic disease	14 (7)
Chronic psychiatric illness	4 (2)
Chronic physical disability and psychiatric illness	11 (5.5)
No major illness, personal reasons	8 (4)
Profile of medical illness
Orthopedic disease	80 (39.8)
Neurological disease	43 (21.4)
Psychiatric illness	5 (2.5)
Respiratory illness	14 (7)
Cardiac disease	6 (3)
Other medical illnesses	37 (18.4)
Mixed	15 (7.5)
Altered sensorium/acute encephalopathy at admission
Yes	23 (11.4)
No	178 (88.6)
Management
Surgery	54 (26.9)
Medical	147 (73.1)
Severe malnutrition at admission
Yes	24 (11.9)
No	177 (88.1)

^&Number (%).

^#Median (25th-75th interquartile range).

Forty three (21.4%) patients had neurological illness, 80 (39.8%) had orthopedic disease, and 37 (18.4%) patients had general medical complications. Severe malnutrition was identified in 42 (11.9%) patients at the time of admissions. Fifty four (26.9%) patients underwent surgery. Altered sensorium was noted in 23 (11.4%) patients at admissions. Majority of patients were managed medically; but, some underwent special procedures and surgeries including arthroplasty, foot amputation, mandibular symphyseal fracture correction, split skin grafting, hernioplasty, bipolar hemiarthroplasty, hemodialysis, dental procedures, urethral sphincterotomy, and specialized neuro-physiological testing. For those who were severely disabled, the ward provided a convenient space for their stay. The physical disabilities required a range of supportive gadgets including wheel chairs, walkers and hearing aids. Orthopedic diseases were predominant among males 61(40.9%). Chronic physical disability was observed in 124 (83.2%) males and 40 (76.9%) females (Table 2). Alcohol addiction was observed in 14 (7%) patients. Eleven (5.5%) patients had psychiatric illness with chronic physical disability. Twenty three (11.4%) were in altered sensorium at admission.

Table 2.

Gender-Wise Analysis of Morbidity Pattern and Recovery.

Variables	Male N (%) &	Female N (%) &	P value*
Reasons for separation from family			.002
Chronic physical disability	124 (83.2)	40 (76.9)
Alcohol addiction	14 (9.4)	0 ()
Chronic psychiatric illness	2 (1.3)	2 (3.8)
Chronic physical disability and psychiatric illness	7 (4.7)	4 (7.7)
No major illness	2 (1.3)	6 (11.5)
System-wise morbidity profile			.013
Orthopedic disease	61(40.9)	19 (36.5)
Neurological illness	35 (23.5)	8 (15.4)
Psychiatric illness	2 (1.3)	3 (5.8)
Respiratory disease	11 (7.4)	3 (5.8)
Cardiac disease	3 (2)	3 (5.8)
Urological disease	1 (0.7)	0 (0)
Other medical illness	21 (14.1)	16 (30.8)
Mixed	15 (10.1)	0 (0)
Recovery status			.234
Recovered	135 (90.6)	44 (84.6)
Death	14 (9.4)	8 (15.4)

^&Number (%).

^*Chi-squared test.

Outcome

Correction of hypovolemia, electrolyte disturbances, and provision of appropriate nutritional support helped a significant number of patients to recover sensorium and cognition. Those who could recollect their residential address were sent home with the aid of social workers, after recovery from illness. Fifty four (26.9%) patients re-united with their families (Table 3). Those who did not have family and those whose families were unwilling to accept them were shifted to asylum/ old age home run by non-governmental voluntary organizations for further care. Twenty two (10.9%) patients expired. There was no significant gender predilection in recovery or mortality (Table 2). The cause of death was categorized as per the National Center for Health Statistics (NCHS; Table 4). Acute myocardial infarction, ICD I21 to I22 (5, 22.7%) and septicemia, A40 to A41 (5, 22.7%) were the leading causes of mortality.

Table 3.

Destination of Patients.

Variable	N (%) &
Reunion with family	54 (26.9)
Transfer to old age home/asylum	125 (62.2)
Death	22 (10.9)

^&Number (percentage).

Table 4.

Cause of Death.

Variable	N (%) &
Acute myocardial infarction, ICD I21 to I22	5 (22.7)
Septicemia, A40 to A41	5 (22.7)
Falls, W00 to W19	2 (9.1)
Other chronic lower respiratory diseases, J44, J47	2 (9.1)
Other disorders of kidney, N27, N27	2 (9.1)
Alcoholic liver disease, K70	1 (4.5)
Emphysema, J43	1 (4.5)
Malignant neoplasm of cervix uteri, C53	1 (4.5)
Motor vehicle accidents, V02 to V04	1 (4.5)
Musculoskeletal system and connective tissue, M00 to M99	1 (4.5)
Other respiratory diseases, J00 to J08	1 (4.5)

Abbreviation: ICD, International Classification of Diseases.

^&Number (%).

Discussion

In this paper, we have described the establishment and functionality of the ward, designated exclusively for providing a holistic care for the untended and abandoned patients with a myriad of illnesses. It is a sad irony that the number of patients without caregivers has been on the rise across India, despite the progress in the economic and social fronts. Post Graduate Institute of Medical Education and Research, a premier medical institution of North India has reported 675 untended patients in 2014 and 574 in 2015. ⁴ Several news columns in Indian newspapers and periodicals have highlighted this issue and analyzed the reasons for this plight. ⁵ But, no systematic analysis has been made and published. Economic constraints and lack of persons in the family to tend to the elderly, infirm and insane people are the prime reasons. Many families cannot afford for admitting such patients in paid old age homes. The contribution of changed ‘values’ of the society also has to be analyzed. Not infrequently, persons with cognitive impairment get out of home unnoticed by other members of the family and are unable to reach back home.

The felt need for establishing a dedicated, all-encompassing unit was realized by the Dean of Madras Medical College (first author). The organizational structure and the assignment of roles of all the stakeholders were clearly defined. Medical and paramedical personnel were selected after ensuring their willingness to work in such a ward. This strategy proved to be a significant attributable factor for the successful outcome of the initiative.

Patients admitted to this ward are from different sources, viz., admitted in different wards and abandoned by family, spotted, and brought by good samaritans from the platforms and streets, brought by police and social activists.

A total of 201 patients benefited since December 2020 to June 2022. Most of the patients were from lower socio-economic strata of the society. Illiteracy was common (80.1%) and 54.2% of the had not been on any regular employment. Orthopedic disease and neurological disease dominated the morbidity profile (39.8% and 21.4%, respectively). Alcohol addiction was noted in 14 (7%) patients. Most patients required long stay (mean length of stay: 50 days) and several multi-speciality consults.

Many unique challenges were encountered while tending care for such patients. (a) Handling patients with psychiatric illness required support of trained staff. (b) Feeding patients with chronic physical disability consumes time and warrants patience. (c) Getting consent for surgical procedures is not possible if the concerned patient lacks insight. In such situations, the administration proceeded with treatment in the best interest of the patients. (d) Handling patients from other states posed linguistic challenges since they were not able to communicate either in Tamil (local language) or English. (e) Constant communication with Social Welfare Department personnel and voluntary agencies was required for hassle-free transfer of patients upon recovery.

Majority (89.1%) of the patients made a gradual recovery/improvement in their physical illness and cognitive impairment. It was a heartening experience to witness 54 (26.9%) patients re-uniting with family. A point to be emphasized is that cognitive impairment improved significantly, but, slowly in many patients after purposeful medical and psychiatric treatment. A diagnosis of Alzheimer’s or other forms of dementia should not be done hastily. Twenty two (10.4%) patients expired. Myocardial infarction and septicemia were the leading causes for mortality.

Team spirit is the key to success in such a venture. Seamless communication among all the members of the team is mandatory. The role of paramedical staff is of paramount importance. Engaging in feeding, dressing, and in ablutions everyday requires a high level of motivation, empathy, and commitment. The hospital administration offered constant encouragement to all the staff and recognized their benevolent services with rewards and certificates of appreciation.

This novel initiative has the credit of being the first-of -it’s kind in the state of Tamil Nadu. To the best of our knowledge, there has not been any such facility in the entire country. After witnessing the benefits of this initiative, two other government hospitals of Tamil Nadu have started similar wards. It would be heartening to see similar dedicated wards established in all major hospitals of the country. Every person of the society deserves care. Provision of care with dignity is a collective responsibility of the society. Neglect of the infirm and insane members would be a slur on the collective psyche of the society.

Conclusion

Number of untended and uncared patients is on the rise. Provision of holistic care for them until a reasonable level of recovery, though challenging, is possible in tertiary care hospitals. A well-structured team comprising of motivated medical, para medical, and support staff is mandatory. With a vigorous and purposeful management, a significant proportion of such patients achieve partial/complete recovery. Our model of such a facility can be replicated in other institutions also.