Care of sick newborns at KNH

Fred Were EBSUON NBS

Scope

• Some background• The workload & bed space; are we

prepared?• The structure; are we ready for the

challenge?• Service Delivery; are we there?

Background- the KNH NBU has grown in;

• Physical infrastructure1. From a small unit at KMTC IN 1980 to a large 7 room unit o first floor2. From a SCU to a level III NICU

• Human resource training1. From a small number of non-neonatology trained medical staff to 6

specialists2. From on-job trained nursing staff to several fully trained experts

• Yonger human resource numbers1. From a Resident Doctor population of 4 to 12-20 2. Many trainee nurses with sufficient skills for the unit

Backgroundtrends in survival/mortality of VLBW infants at KNH

1970s

1980s

1990s

2000s

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

48

48.7

51.7

46.8

52

51.3

48.3

43.2Survivors Deaths

Percentage of admission/birth cohort

Dec

ade

Meme JS, MMED Thesis, Kasirye EAMJ 1992;69, Mukhwana EAMJ 2002; 79, Were F 2009 EAMJ 374

Message

• There has been no improvement in survival of

VLBW infants at this unit in 4 decades despite

other apparent changes of health systems.

• Mukhwana’s study actually demonstrated that

less than 30% of VLBW pretems survived the

newborn period

THE WORKLOAD; ARE WE PREPARED?

Workload-Current estimates/year

KNH Birth Cohort

About 6000 live births

About 6000 will require

care

Transfers into KNH

About 50,000 born in surrounding

institutions/home

Contribute 150 to the burden at KNH

Workload-Estimated Increase Burden in free mat care era

KNH

Birth Cohort7500 lbs

750 will require care

75 will need Level III

Surrounding Facilities

Birth Cohort50,000 lbs

5000 will need care

500 need Level III

This will lead to requirement of more NICU spaceThe bed capacity needs are determined by;

• The birth cohort in the catchment area (KNH & Surrounding facilities without NICU)

• The projected complication rates (Prematurity, Asphyxia rates e t c)

• Patient selection policies (All preterms versus ≥28weeks)

Requirements of NICU space

Developed countries

• Low complications rates

1. Prematurity/LBW <5%2. Asphyxia <1%

• Need 1 NICU bed/2000live birth

KNH (Low Resource Settings)

• High complications rates

1. Prematurity/LBW rates >10%2. Asphyxia rates nearer 5%

• ? 1 NICU bed /1000live births

It is recommended that the smallest NICU should be 4 bed to break even And at least 12 beds to achieve maximal cost benefit

Gaps and Opportunities

• The demand for NICU services is high in KNH

• The demand is even higher in the expanded metropolis

• There is an apparent upsurge of patients capable of paying for the services

• KNH can place herself as a cost-beneficial /even profitable unit

THE STRUCTURE; ARE WE READY FOR THE CHALLENGE?

Structural OrganizationLEVEL Type of Care Venue

I (Nursery) Short term observation and final convulscence

Within maternity unit

II (Special Care)

Cardio-respiratory monitoringIntermediate interventions

In the NBU

III (Intensive care)

Cardio-respiratory supportIntensive observationsComplicated interventions

In a specialized unit

The Modern Structure of NBSBed distribution

Option 1All NICU beds have ventilators able to deliver CPAP

2-3 level II beds per ventilator bed

Option 2½ the NICU beds have ventilators able to provide CPAP

½ the NICU beds be CPAP only

2-3 level II beds per ventilator/CPAP

Proposed KNH Model

Optimizing present state

4 Ventilator beds with independent CPAP delivery

4 primary CPAP beds

24 level 2 beds

Twice the current level 1 capacity

Upgrading towards meeting demand

12 Ventilators beds able to provide CPAP

12 primary CPAP beds

72 level II beds

3Xthe current level I capacity

Gaps and opportunities

• The present bed

capacity is grossly

inadequate for even the

KNH cohort alone

• The overall organization

is also sub-optimal

• Current political interest

in MNCH

• Increasing interest in

MNCH by

philanthropists and

donors

SERVICE DELIVERY; ARE WE THERE?

The Ideal unit should be covered by

• Senior clinicians/Nurses with knowledge and skills needed for all the levels of care working at 42-48 hr week

• Mid level clinicians/nurses with working 48-60 hour week;

• Other necessary support staff (specialist paediatricians, radiologists)

The Ideal unit should also have

• Dedicated emergency laboratory services

available (including emergency self use)

• Easily accessible emergency radiology services

with near ZERO turn around time

• Rapidly accessible additional consultant

services (surgical, other paediatric specialties)

Such a unit should also have an appropriate HR structure

M M ED II O R O TH ER SK ILLED M ED O FFIC ER Sthese w ill do leve l I & II du ties and ca lls as they

shadow the leve l above

N EO N ATAL FELLO W S (PO ST M M ED TR AIN EES )YEAR II/III M M E D

these w ill do prim ary N IC U duties and ca lls

C O N SU LTAN T N EO N ATO LO G IST S

M ED IC AL TR AC K

TR AIN EE N IC U N U R SES

AD EQ U ATE TR AIN N ED SH IFT C O VER AG E

2 SEC TIO N H EAD SFU LLY TR AIN ED SH IFT LEAD ER S

C H IEF N U R SE

N U R SIN G TR AC K

O VER AL LEAD ER(M ED IC AL)

Gaps and opportunities

• No Fellowship training

• No care guidelines for

unit

• Inadequate medical

products

• Abundant training

demand in region

• Political good will for

development