Symposium on Improving Survival of the Critically Ill Mothers and Neonates

1. 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

2. 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 • Definitions – Critical Care, Critically Ill Mothers • Status and Preparedness of the Kenyan Health System to Provide Care • Challenges Encountered in Management of these Conditions in Kenya • Definition: Quality of Care • Suggestions on Ways to Improve Quality of care for Critically ill Mothers

3. Definitions 1–Critical Care, • Critical Care –the term denotes…provision of a high level of medical care, but not necessarily from a unit specialized for the same…. • 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. • 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; • 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;

4. 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!

5. 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!

6. Reasons for ICU admission of obstetric patients…… Summarized into 3 broad categories: • Conditions related to pregnancy – eclampsia, severe pre-eclampsia, obstetric haemorrhage, amniotic fluid embolus, acute fatty liver, and peripartum cardiomyopathy, amniotic fluid embolism, aspiration syndromes, infections etc. • Medical diseases that may be aggravated during pregnancy – congenital heart diseases, rheumatic and non-rheumatic valvular diseases, pulmonary hypertension, anemia, renal failure etc. • Conditions that are not related to pregnancy – trauma, asthma, diabetes, autoimmune diseases etc.

7. 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 high-dependency unit (HDU) if available.

8. 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 IsioloCounty with the lowest (42 HFs, 0.5%); • Ownership: 49% public, 33% private-for-profit, 16% private-not-for-profit; • 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.

9. 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)

10. In 2011, there were 7 hospitals in the public sector offering ?critical care services / with ICUs, namely:

11. 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

12. ICU beds – Phased Future Plans

13. Key Human Resources for Health in 2011

14. Health Workforce Availability in Kenya in 2013 – Generalists vs. Specialists

15. Key 2014 HRH data – Some Critical Care Doctors

16. Key 2014 HRH data – Other Critical Care Cadres

17. Cost perspectives for Establishing ICU care

18. Indications for ICU admission of obstetric patients…… Summarized into 3 broad categories: • Conditions related to pregnancy – eclampsia, severe pre-eclampsia, obstetric haemorrhage, amniotic fluid embolus, acute fatty liver, and peripartum cardiomyopathy, amniotic fluid embolism, aspiration syndromes, infections etc. • Medical diseases that may be aggravated during pregnancy – congenital heart diseases, rheumatic and non-rheumatic valvular diseases, pulmonary hypertension, anemia, renal failure etc. • Conditions that are not related to pregnancy – trauma, asthma, diabetes, autoimmune diseases etc.

19. Challenges Encountered in Management of these Conditions In a clinical set-up…primary challenges revolve around: • The Gravid Uterus – it gives Supine Hypotension Syndrome to the mother; • The need to care for two lives – requiring a team approach, especially the involvement of the Obstetrician to take care of the baby; • The viability of the foetus, advantages and disadvantages in continuation of the pregnancy and the mode of delivery, if required; • 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;

20. Secondary Challenges – Inadequate Health Financing • 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 • 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

21. 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: • Access to services • Adequate supplies and equipment • Application of evidence-based clinical protocols • Technical, managerial and interpersonal skills of health staff

22. Essential Elements of quality of care • Safety: Avoiding injuries to patients from the care that is intended to help them. • Effectiveness: Providing services based on scientific knowledge and best practice. • 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. • Timeliness: Reducing waits and sometimes harmful delays for both those who receive and provide care. • Efficiency: Avoiding waste, including waste of equipment, supplies, ideas and energy. • Equitability: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

23. What Determines Quality of Care? • Primary • Infrastructure for Service Delivery • Human Resources for Health • Essential Medicines and Medical Supplies • Secondary • Governance • Health Records and Information System • Health Financing

24. Suggestions on Ways to Improve Quality of Care • I believe government should bear ALL the costs of keeping its citizenry healthyas 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

25. 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.

26. Referrences…………. • Kenya SARAM Report, October 2013http//:www.who.int/healthinfo/systems/saraintroduction/en/index/html • The Ministry of Medical Services Business Plan, 2011 • MPDB Data Base, 2014 • NCK Data Base, 2014 • COC Data Base, 2014