Audit report finds lapses, inadequacies, mismanagement in '108 Emergency Services' in Karnataka
An audit report conducted by the Principal Accountant General (Audit 1), Karnataka on the functioning of the Aarogya Kavacha (108 Emergency Services) in Karnataka has found lapses, inadequacies, mismanagement, and reported non-performance by the personnel of the service.
The audit report by the Principal Accountant General (Audit 1), Karnataka was conducted with two main objectives - Examining the adequacy and responsiveness in the delivery of quality emergency medical services by the Arogya Kavacha–108 project and Examining whether the IT system deployed in the project was adequate in delivering quality care.
The audit also took note of one incident where the ambulance crew stopped for dinner during which the caller made four follow-up calls to enquire about the arrival of the ambulance. Since the ambulance did not arrive even after 80 minutes, the patient was transported to a hospital in a private vehicle and died.
It also observed the lack of a call-back mechanism for the operators to call back the callers in case they were unable to attend to the incoming calls or if the call gets disconnected. According to the audit, a case was noticed where the operator could not call back the caller after the call was disconnected leading to the death of the patient.
The audit evaluated the performance of the services in eight of the 30 districts of the state. It also included inspection of 25% of ambulances in each district, structured interviews with emergency medical technicians, pilots, and emergency department staff in district hospitals, the beneficiary survey of those admitted in the district hospitals, etc.
According to the audit, the 108 service call centers in Karnataka attended 253.30 lakh calls out of 256.45 lakh calls between April 2014 and March 2019. Of the 253.30 lakh calls, the audit reported only 36% (91.62 lakh) were effective calls. The rest, 64% (161.68 lakh) were ineffective calls i.e. no response calls, missed calls, nuisance calls, wrong calls, prank calls, etc.
Of the 91/63 lakh effective calls, 44% were non-emergency calls i.e. inquiry calls, follow-up calls, caller concerns, and appreciations, calls from field staff seeking clarifications, etc.
According to a Union Ministry of Road Transport and Highways’ report “Road Accidents in India 2018”, India accounted for 11% of all accidents-related deaths across the world while having only 1% of the world’s vehicles.
It is indeed likely, that some of these lives could have been saved had the victims received prompt and adequate emergency medical care. In fact, in the Pt Parmanand Katara vs. Union of India and Ors case (1989), the Supreme Court held that Article 21 of the Constitution includes the right to emergency medical care. The SC had also emphasized the importance of the “Golden hour” i.e ‘the time period lasting one hour following a traumatic injury during which there is the highest likelihood of preventing death by providing prompt medical care.
Indian Audit and Accounts Service (IAAS) officers, EP Nivedita and Pavan Kumar Reddy in their article for Bengaluru.citizenmatters.in stated “Since such a humongous volume of ineffective/non–emergency calls were certain to affect service quality adversely, measures such as providing an alternate number for inquiries, educating the public about the use of 108 for emergencies only, penalizing those who indulge in prank calls, sharing the contact details of the ambulance crew with the caller, etc should have been implemented.”
“Accurate pre-arrival instructions to emergency callers before help arrives at the scene is a well-recognized practice in emergency situations. These instructions are potentially life-saving in many cases. However, the audit observed that Emergency Response Officers (ERO) and Despatch Officers (DO) were not trained to provide pre-arrival instructions to callers.” The two officers mentioned in their report.
An indicative list of observations is given below:
The mandated response time for cardiac, respiratory, stroke, and accident cases is 10 minutes. However, the actual response time for all these types of emergencies was above 10 minutes in more than 60% of cases. Further, in 50% of trauma cases, the patients were admitted to the hospital after the “golden hour”.
An ambulance can be deployed afresh only after the case on hand is closed. The prevailing practice was that the ambulance crew closed the case only on reaching the base location. Analysis of timelines revealed that in 89% of cases the ambulance crew did not report the closure of cases immediately after reaching the base location. Audit noticed a case wherein the two nearest ambulances at the base station were not allotted to the patient because the ambulance crew had not closed the previous case. The call center allotted the fourth nearest ambulance which was far away. The patient did not survive.
“Today we have a surfeit of IT tools which can enable precise measurement and analysis of voluminous data. However, we observed that the project suffered from various data integrity issues such as manual data capture, incorrect reporting by the ambulance crew, null values for the type of emergency, manual insertion of cases, back-end updating of data, unrealistic data points like transportation of more than 20 patients at a time in multiple cases, etc.” Nivedita and Pavan added in their article.
“Such weaknesses render data unusable for corrective action. One serious inconsistency noticed was in the recording of Chute Time i.e the time taken between the assignment of an ambulance and the moment it starts moving towards the scene. The software recorded chute time uniformly as one minute without capturing the actual time taken.
“Based on GIS data, the audit analyzed the chute time of 38,737 cases for the period January 2019 to June 2019 and found that in 60% of cases it was more than 10 minutes. This is a painful loss of time which can be a matter of life and death for patients.” The article further added.
The private service provider was appointed by the government without any competitive bidding, by obtaining exemption under Karnataka Transparency in Public Procurement (KTPP) Act for this Public Private Partnership (PPP) arrangement. Further, the nature of the contract with the service provider and its implementation has a massive impact on the latter’s performance.
“Audit observed that the Memorandum of Understanding (MoU) entered into by the state government with the private partner had several shortcomings –absence of penalty for deficient delivery of services, failure to specify qualifications for various personnel, lack of any protocol for handling grievances, non-existence of separate service level agreements for IT systems, absence of exit strategy plan post contract period, etc. Zero tolerance for non-performance as per prescribed service levels and foolproof mechanisms for establishing accountability and transparency should have been factored into the contract and its enforcement.” It added.
In addition to the above, the audit report highlights other serious issues. Like the huge shortage of pilots and Emergency Medical Technicians leading to stress on available resources, use of ambulances for non-emergency purposes, the double despatch of ambulances, disruptions in communication, non-availability of automated location identification based on calls, allocation of Basic Life Support (BLS) ambulances to cases that require Advanced Life Support (ALS) ambulance, etc.
Thus, a noteworthy government initiative to provide emergency medical services was marred by various deficiencies as mentioned above. The audit report which includes specific recommendations to the government for consideration and early adoption was presented to the state legislature on September 12th, 2020. It can be accessed at https://cag.gov.in/en/audit-report/details/112920 (English and Kannada versions).
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Los Angeles county wildfires could be costliest in US history, early estimates say
Los Angeles, Jan 11: The wildfires that erupted this week across Los Angeles County are still raging, but already are projected to be among the costliest natural disasters in US history.
The devastating blazes have killed at least 11 people and incinerated more than 12,000 structures since Tuesday, laying waste to entire neighbourhoods once home to multimillion-dollar properties.
While it's still too early for an accurate tally of the financial toll, the losses so far likely make the wildfires the costliest ever in the US, according to various estimates.
A preliminary estimate by AccuWeather put the damage and economic losses so far between USD 135 billion and USD 150 billion. By comparison, AccuWeather estimated the damage and economic losses caused by Hurricane Helene, which tore across six southeastern states last fall, at USD 225 billion to USD 250 billion.
“This will be the costliest wildfire in California modern history and also very likely the costliest wildfire in US modern history, because of the fires occurring in the densely populated areas around Los Angeles with some of the highest-valued real estate in the country,” said Jonathan Porter, the private firm's chief meteorologist.
AccuWeather factors in a multitude of variables in its estimates, including damage to homes, businesses, infrastructure and vehicles, as well as immediate and long-term health care costs, lost wages and supply chain interruptions.
The insurance broker Aon PLC also said Friday that the LA County wildfires will likely end up being the costliest in US history, although it did not issue an estimate. Aon ranks a wildfire known as the Camp Fire in Paradise, California, in 2018 as the costliest in US history up to now at USD 12.5 billion, adjusted for inflation. The Camp Fire killed 85 people and destroyed about 11,000 homes.
The LA County wildfires, which were fuelled by hurricane-force Santa Ana winds and an extreme drought, remained largely uncontained Saturday. That means the final tally of losses from the blazes is likely to increase, perhaps substantially.
“To put this into perspective, the total damage and economic loss from this wildfire disaster could reach nearly 4 per cent of the annual GDP of the state of California,” AccuWeather's Porter said.
In a report Friday, Moody's also concluded that the wildfires would prove to be the costliest in US history, specifically because they have ripped through densely populated areas with higher-end properties.
While the state is no stranger to major wildfires, they have generally been concentrated in inland areas that are not densely populated. That's led to less destruction per acre, and in damage to less expensive homes, Moody's noted.
That's far from the case this time, with one of the largest conflagrations destroying thousands of properties across the Pacific Palisades and Malibu, home to many Hollywood stars and executives with multimillion-dollar properties. Already, numerous celebrities have lost homes to the fires.
“The scale and intensity of the blazes, combined with their geographic footprint, suggest a staggering price tag, both in terms of the human cost and the economic toll,” Moody's analysts wrote. The report did not include a preliminary cost estimate of the wildfire damage.
It could be several months before a concrete tally of the financial losses from the wildfires will be possible.
“We're in the very early stages of this disaster,” Porter said.
