Care of sick newborns at KNH

1. Care of sick newborns at KNH Fred Were EBS UON NBS

2. Scope • Some background • The workload & bed space; are we prepared? • The structure; are we ready for the challenge? • Service Delivery; are we there?

3. Background- the KNH NBU has grown in; • Physical infrastructure • From a small unit at KMTC IN 1980 to a large 7 room unit o first floor • From a SCU to a level III NICU • Human resource training • From a small number of non-neonatology trained medical staff to 6 specialists • From on-job trained nursing staff to several fully trained experts • Yonger human resource numbers • From a Resident Doctor population of 4 to 12-20 • Many trainee nurses with sufficient skills for the unit

4. Backgroundtrends in survival/mortality of VLBW infants at KNH Meme JS, MMED Thesis, Kasirye EAMJ 1992;69, Mukhwana EAMJ 2002; 79, Were F 2009 EAMJ 374

5. 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

6. THE WORKLOAD; ARE WE PREPARED?

7. Workload-Current estimates/year

8. Workload-Estimated Increase Burden in free mat care era

9. 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)

10. Requirements of NICU space Developed countries KNH (Low Resource Settings) High complications rates Prematurity/LBW rates >10% Asphyxia rates nearer 5% ? 1 NICU bed /1000live births • Low complications rates • Prematurity/LBW <5% • Asphyxia <1% • Need 1 NICU bed/2000live birth It is recommended that the smallest NICU should be 4 bed to break even And at least 12 beds to achieve maximal cost benefit

11. 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

12. The structure; are we ready for the challenge?

13. Structural Organization

14. The Modern Structure of NBSBed distribution

15. Proposed KNH Model

16. 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

17. Service delivery; are we there?

18. 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)

19. 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)

20. Such a unit should also have an appropriate HR structure

21. Gaps and opportunities • No Fellowship training • No care guidelines for unit • Inadequate medical products • Abundant training demand in region • Political good will for development