Symposium on Improving
Survival of the Critically Ill
Mothers and Neonates
By Dr Simon Mueke
Head, RMHSUnit
DFH, MOH
Friday 8.30am, February 7, 2014
Who are Critically Ill Mothers?
Status and Preparedness of the Kenya Health System to Provide Care….
Challenges Encountered in management of these Conditions across the
Country & Suggestions on Ways to Improve Quality of Care.
OUTLINE
1. Definitions – Critical Care, Critically Ill Mothers
2. Status and Preparedness of the Kenyan Health System to Provide Care
3. Challenges Encountered in Management of these Conditions in Kenya
4. Definition: Quality of Care
5. Suggestions on Ways to Improve Quality of care for Critically ill Mothers
Definitions 1–Critical Care,
1. Critical Care –the term denotes…provision of a high level of
medical care, but not necessarily from a unit specialized for the
same….
2. It is care that can be provided in any set up… in a transport vehicle,
out-patient department, general hospital ward, operating theatre or
indeed anywhere one finds the patient.
3. This type of care is considered primary or resuscitation-based, and
thus it is vital; primary resuscitation should always be performed
before transferring a patient to the definitive ICU for optimum care;
4. Critical Care therefore encompasses not just ICU per se, but also
High Dependency Units, Kidney Dialysis Units, Operating Theatres,
Burn Units, Cardiology Units, Stroke Units, etc;
SOPs / Guidelines for a generic Critical Care Unit
• Adequate staff appropriately trained in critical care (at least, a resident medical
doctor, anaesthesiologist, surgeon, critical care physician, nurses, physiotherapists,
nutritionists, laboratory technicians, biomedical technologists, pharmacists,
counselors, and support staff; the patient:nurse ratio should be 1:1;
• Each ICU bed comes with a mechanical ventilator, cardiac monitor, at least two
drug-infusion pumps and suction apparatus; in addition, at least one each of the
following are needed: a portable X-ray machine, an Ultra-Sound/Doppler scanner, a
12-lead electrocardiogram machine, a Haemodialysis machine, and proximity to a
CT-Scan machine;
• Every ICU should have an in-built laboratory with capacity to do the following
investigations: Arterial blood gas analysis; urea, creatinine and electrolytes; full
haemogram; blood sugars; cardiac enzymes; inflammatory markers and liver function
tests. Other specialized tests like microscopy, cultures and bacterial sensitivity, can be
carried out in the main hospital laboratories;
• A well stocked pharmacy, complete with a resident pharmaceutical specialist, is
mandatory. A nutritionist should liaise with the pharmacist to avail all necessary
special feeds at all times;
• All the ICUs shall be interconnected via fibre-optic internet cables and shall be
“paperless” all over the country by the year 2030!
Definitions 2– Critically Ill Mothers.
• Is this important?
• Admission of pregnant or postpartum women to the ICU is uncommon but
may require specialized knowledge for successful management
Stephen Lapinsky, Crit Care Med 2005; 33: 1616-1622
• The Magnitude of the Problem
• For every maternal death, there are 70-80 “near misses”; these are the
women who become critically ill and would otherwise require ICU care.
• Obstetric admissions account for 0.9-1.5% of all ICU admissions; with 3% of
them dying, Research shows…..in advanced countries!
Reasons for ICU admission of obstetric patients……
Summarized into 3 broad categories:
a) Conditions related to pregnancy – eclampsia, severe preeclampsia, obstetric haemorrhage, amniotic fluid embolus,
acute fatty liver, and peripartum cardiomyopathy, amniotic
fluid embolism, aspiration syndromes, infections etc.
b) Medical diseases that may be aggravated during pregnancy –
congenital heart diseases, rheumatic and non-rheumatic
valvular diseases, pulmonary hypertension, anemia, renal
failure etc.
c) Conditions that are not related to pregnancy – trauma,
asthma, diabetes, autoimmune diseases etc.
ICU admission criteria for such patients would
vary but…….generally,
• If two organ systems are failing with a need for ventilation
support, an ICU admission should be mandatory and
• Otherwise, less sick patients should be cared for in a highdependency unit (HDU) if available.
Current Status & Preparedness of the Kenyan Health System to
Provide Care to Critically Ill Mothers – 1
• Population: Today, Kenya has about 44,000,000 people;
• Health Facilities: There are 8401 HFs: Nairobi County with the highest
(875 HFs, 10.4%), and Isiolo County with the lowest (42 HFs, 0.5%);
• Ownership: 49% public, 33% private-for-profit, 16% private-not-forprofit;
• Location: 66% HFs are rural, 33% HFs are urban;
• Traditionally, Hospitals make 7% of all health facilities; M/N Homes – 4%,
H/Centers – 13%, Dispensaries – 46% and Private Clinics – 31%;
• Patient Transport: there are 502 functional ambulances in use, with 1.22
ambulances per 100,000 population; highest-Embu County at 5.23,
median- Mombasa County at 1.09 and lowest-Kisumu County at 0.09
ambulances per 100,000 people.
Current Status and Preparedness of the Kenyan Health System to
Provide Care to Critically Ill Mothers – 2
• In 2013, Kenya had 11,937 HF beds (out of an expected 61,600
beds for such a population – World Bank Report 2012): with 108
critical care beds, 3,266 maternity beds and 11,633 other beds;
• According to the Hospital Bed Project 2011, the bed density was
1.4 beds/1,000 population (better than all regional neighbors);
• But the Kenya SARAM Report 2013 reported a bed density
reduction from 1.4 to 0.25 beds/1,000 population (although
there is no global recommendation);
• The Kenyan General Ward : ICU bed ratio therefore is 110:1
(WHO recommends a GW:ICU bed ratio of 50:1)
In 2011, there were 7 hospitals in the public sector offering
?critical care services / with ICUs, namely:
S/No Hospital
Bed
No. of
No. of
No. of
Capacity ICU Beds Anesthesiol. ICU Nurses
1
Kenya National Hospital
1,800
42
26
150
2
3
Moi Teaching & Referral Hospital
PGHospital, Mombasa
750
700
6
2
5
3
18
2
4
5
PGHospital, Nakuru
PGHospital, Kisumu (JOOTRH)
650
600
4
4
2
2
9
2
6
7
PGHospital, Nyeri
Kisii Level 5 Hospital
TOTALS
500
450
5,450
3
3
64
1
1
40
2
6
189
In 2013, there were 50 hospitals with ICUs in the sector
and 30 with HDUs, thus:
• Out of 47
counties, 20
have critical
care services
• Out of 607
hospitals in
Kenya in 2013,
there were 50
with ICUs and
30 with HDUs
County
#Hosps
#Hosp
with
ICUs
#Hosp
with
HDUs
1
Nairobi
78
9
8
2
Mombasa
15
14
3
Nakuru
17
4
Nyeri
5
#Hosps
#Hospital
s with
ICUs
#Hosps
with
HDUs
11 Machakos
8
1
1
3
12 Garissa
9
1
1
4
4
13 Bomet
5
1
1
40
3
2
14 Kakamega
16
1
0
Kisii
18
3
2
15 Murang’a
10
1
0
6
Kisumu
17
3
2
16 E/Marakwet
9
1
0
7
U/Gishu
12
2
1
17 Samburu
4
1
0
8
Migori
12
2
1
18 Kiambu
52
0
1
9
Bungoma
11
2
0
19 Kericho
11
0
1
13
1
1
20 Kilifi
11
0
1
379
50
30
10 Kitui
County
ICU beds – Phased Future Plans
Target
Public
Private
Total
In 2011
37 beds
57 beds
94 Beds
In 2012
64 beds in 7 hospitals
15 hospitals 22 Hospitals
(KNH, MTRH, CPGH, NPGH, Nyeri PGH, JOORTH, and Kisii level 5 Hospital)
By 2015
Phase 1
88-132 beds in 11 other hospitals
By 2020
Phase 2
80-128 beds in 16 other hospitals
By 2025
Phase 3
50-80 beds in 10 other remaining County Referral Hospitals
Kitui DH, Msambweni DH, Murang’a DH, Taveta DH, Mwingi DH,
Kajiado DH, Nyahururu DH, Homa Bay DH, Migori DH and Makueni DH
By 2030
At least, all County Referral Hospitals and the other larger hospitals to have CCUs by 20130!!!!
Garissa PGH, Embu PGH, Meru D.H, Thika D.H, Machakos D.H, Kiambu D.H, Nyeri PGH,
Kakamega PGH, , Kisii D.H, Kitale D.H,and Meru D.H.
Kiambu D.H, Bungoma D.H, Homa Bay D.H, Siaya D.H, Kericho D.H, Nyanyuki D.H, Lodwar
D.H, Malindi D.H, Wajir D. H, Mandera D.H, Marsbit D.H, Moyale D.H, Voi D.H, Naivasha
D.H, Narok D.H, and Busia D.H.
Key Human Resources for Health in 2011
(MOMS Business Plan 2011)
Number
Some Cadres
Registered
Medical Officers
Dentists
Lab Technologists
Nurses
Clinical Officers
Physiotherapists
TOTAL HEALTH
WORKFORCE
Numbers
available
Public Private Optimal
Sector Sector Number
Gap
Analysis
Against
Total
Public Shortfall
7,561
888
4,997
27,048
8,917
1,387
2,111
264
2,107
17,048
3,334
578
5,134
624
2,890
10,000
2,500
809
27,762
11,188
6,568
172,900
23,207
19,565
25,651
10,924
4,461
155,852
19,873
18,987
20,201
10,300
1,571
145,852
14,290
18,178
50,798
25,442
21,957
261,190
235,747
210,392
Health Workforce Availability in Kenya in 2013 –
Generalists vs. Specialists
Key Health Cadre -
Generalists
2013 No.
Available
Key Health Cadre –
Specialists
2013 No.
Available
1 Medical Officers
2,239
1 Obstetrician/Gynecologists
207
2 Clinical Officers
4,723
2 Physicians
501
3 Paediatricians
324
4 General Surgeons
233
3 Nurses
4 Medical Lab Officers
24,187
4,424
5 Nutritionists
496
5 Midwives
6 Physiotherapists
477
6 ICU Nurses
249
7 Drivers
845
7 Theatre Nurses
119
8 Radiographers
347
8 Anaesthesiologists
316
9 Medical Eng. Technologists
417
9 Radiologists
112
67,075
10 Pharmacists
1,021
10 Total Health Workforce
Only 15% of the staff were absent at the time of the assessment, duly
authorized; Leaves, Training, etc. (the Kenya SARAM Report 2013)
1,728
Key 2014 HRH data – Some Critical Care Doctors
Key Specialists
All Registered
In Post with MOH
In Private or Abroad
1
Obstetrician/Gynecologists
340
84
26
2
Physicians
172
52
120
3
Anaesthiologists
120
29
91
4
General Surgeons
228
86
142
Specialists
In Post with
Ministry / Counties
In How Many
Public Hospitals
In How Many
Counties
1
Obstetrician/Gynecologists
84
65
41
2
Physicians
52
47
34
3
Anaesthesiologists
29
27
22
4
General Surgeons
86
64
40
5
Paediatricians
79
64
39
Key 2014 HRH data – Other Critical Care Cadres
Key Cadre
All Registered
In Post with MOH
In PP / Abroad
1
Clinical Officers (RCOs)
13,100
3,700
9,400
2
RCO Anaesthetists
800
254
546
3
RCO RH
80
60
20
4
Nurses/Midwives
50,783
5
Nurses/Critical Care
301
6
Nurses/Neonatology
14
Cost perspectives for Establishing ICU care
Cost (Kshs)
An ICU bed
6,000,000/-
Setting up an ideal ICU laboratory
15,000,000/-
ICU hospitalization for 1 day only
3,000 – 30,000/-
Training an Intensivist
5,000,000/-
Training an ICU nurses
2,000,000/-
1 ICU with 6-10 beds and the
accompanying infrastructure, with
trained staff, lab and other………..
66,000,000/- for trained staff,
infrastructure and startup supplies.
Indications for ICU admission of obstetric patients……
Summarized into 3 broad categories:
a) Conditions related to pregnancy – eclampsia, severe preeclampsia, obstetric haemorrhage, amniotic fluid embolus,
acute fatty liver, and peripartum cardiomyopathy, amniotic
fluid embolism, aspiration syndromes, infections etc.
b) Medical diseases that may be aggravated during pregnancy –
congenital heart diseases, rheumatic and non-rheumatic
valvular diseases, pulmonary hypertension, anemia, renal
failure etc.
c) Conditions that are not related to pregnancy – trauma,
asthma, diabetes, autoimmune diseases etc.
Challenges Encountered in Management of these Conditions
In a clinical set-up…primary challenges revolve around:
1. The Gravid Uterus – it gives Supine Hypotension Syndrome to the
mother;
2. The need to care for two lives – requiring a team approach, especially
the involvement of the Obstetrician to take care of the baby;
3. The viability of the foetus, advantages and disadvantages in
continuation of the pregnancy and the mode of delivery, if required;
4. The physiological changes associated with pregnancy and
puerperium, the specific medical diseases peculiar to pregnancy and
the need to take care of both the mother and the foetus;
Secondary Challenges – Inadequate Health Financing
1.
2.
3.
4.
Few, if any, qualified staff,
No equipment worth talking about.
Equipment purchase not based on any rationale;
Sustainable supplies of non pharmaceuticals that are expensive are
not procured by KEMSA
5. Financial constraints with competing needs.
It is the government responsibility to provide critical care to its
citizens; There is no budget line for critical care yet government
should provide for these services in their entirety
Definitions 3 - Quality of Care
Quality of Care • Two principal dimensions: access and effectiveness;
• Two key components within “Effectiveness” – Effectiveness of clinical
care and Effectiveness of interpersonal care;
• The Framework relates quality of care to individual patients and
introduces other key aspects like equity and efficiency;
• Quality of care encompasses:
o Access to services
o Adequate supplies and equipment
o Application of evidence-based clinical protocols
o Technical, managerial and interpersonal skills of health staff
Essential Elements of quality of care
1. Safety: Avoiding injuries to patients from the care that is intended to help them.
2. Effectiveness: Providing services based on scientific knowledge and best practice.
3. Patient-centeredness: Providing care that is respectful of and responsive to
individual patient preferences, needs and values, ensuring that patients' values
guide all clinical decisions.
4. Timeliness: Reducing waits and sometimes harmful delays for both those who
receive and provide care.
5. Efficiency: Avoiding waste, including waste of equipment, supplies, ideas and
energy.
6. Equitability: Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socio-economic
status.
What Determines Quality of Care?
• Primary
o Infrastructure for Service Delivery
o Human Resources for Health
o Essential Medicines and Medical Supplies
• Secondary
o Governance
o Health Records and Information System
o Health Financing
Suggestions on Ways to Improve Quality of Care
• I believe government should bear ALL the costs of
keeping its citizenry healthy as a lot of foreign
exchange is going abroad;
• To achieve reasonable and equitable access to critical
care services, we need to have at least one hospital
with an ICU of the level and standard of KNH’s in each
and every one of the 47 counties; some larger and
more populated counties may even require more than
one ICU equipped hospital within them;
24
Suggestions on Ways to Improve Quality of Care
• First is Training requisite staff; Second is standardizing
and costing a CCU; Third is allocating funds for
construction of these units; finally, allocating
recurrent expenditure to sustain the services in the
facility;
• Exploring the “Public-Private Partnership” principles
for a faster expansion to increase access to critical
care services in Kenya.
Referrences………….
1. Kenya SARAM Report, October 2013
http//:www.who.int/healthinfo/systems/saraintroduction/en/index/html
2.
3.
4.
5.
The Ministry of Medical Services Business Plan, 2011
MPDB Data Base, 2014
NCK Data Base, 2014
COC Data Base, 2014