J. Adabie Appiah Head PICU, KATH Pediatric Critical Care: A new approach to saving children's lives challenges and the way forward J. Adabie Appiah Head PICU, KATH

Definitions Critical care: system of care aimed at identifying clinically deteriorating hospitalized children, in a timely manner, so that experienced clinicians to resuscitate and stabilize Intensive care: service to support patients with threatened or organ failure as a result of an acute illness, injury or predictable phase in a planned treatment (post surgery) which is potentially recoverable. Delivered in a unit Appropriately staffed and equipped with doctors, nurses and other health workers from multi-disciplinary team

Critical care remains a neglected area of health service delivery in Africa, with large numbers of patients with potentially treatable conditions not having access to such services. Further advocacy is necessary to highlight these challenges and to provide sustainable solutions for ensuring access to good quality, inexpensive, basic critical care.

Critical care medicine in Africa is largely an unknown Adhikari et al., 2010, Riviello et al., 2011

Ped Intensive Care Units in Africa Exceptions South Africa and North Africa East Africa (Population 202m) Kenya – 2 Uganda - 1 Rwanda -? West Africa (Population - 301 m) Ghana – 1 Nigeria – 0

Ebola – the wake up call Cost of setting up an infrastructure for early effective response is insignificant compared to the huge social and economic cost of the outbreak. Strong health system, Improved preparedness Effective community participation. Lamontagne, F., et al., NEJM, 2014

Facilities for critically ill

Burden of critical illness Scanty data on critical illness in Africa Critical illness is common in areas of the world plagued with minimal resources to deal with its ravages. N. Kissoon. PCCM 2011 KATH – PEU mortality 2002-2004 12% Admissions/yr: 1900 2005-2013  6% Admissions/yr: 2800 PEU stay > 2 days = 10 - 15% of all admissions Mortality = 40 - 61% KATH Performance Review, 2005, 2015

What do we need?

Multi-disciplinary PICU – February 2015 To address patient care need Training needs

Intervention needed in PICU Primary outcome Total Gen ICU admission (2008-2014) Total pediatric admissions 270 Survivors 148 (56%) Total PICU admission 266, survivors 203 (76%) Intervention needed in PICU IPPV - 76%, 48% - circulatory support, 15% monitoring, neuro-support 10%

Age classification

Reason for admission

Patient Outcome Morality in LIC and HIC ICUs) 30–50% and 8–25% respectively Kwizera et al. 2012; Halpern et al. 2004

Are we ready for equity? Is it possible that everybody everywhere has access to basic acute care services, before we can provide advanced (“privilege”) care to children? (P)ICUs might not significantly decrease the overall mortality rate in resource poor countries but Ripple effect of quality care (critical thinking, infection control, quality assurance etc)

How did we get here? First in the West Africa Initiative by Child Health Unit of KATH Hospital management involved Collaboration with UCT/RCWMCH Medical, nursing and technical personnel Finding space in an overcrowded facilities Equipment availability/procurement Sustainability – funding, ongoing training,

Preparatory activities 2011 – 2013: Training of one pediatric intensivist and two pediatric critical care nurses in South Africa with Africa Pediatric Fellowship Program support 2014 – Identification of PICU location and equipment sourcing

Ped Critical Care Team was established to manage critically ill patients. This helped created awareness and support among the pediatric and neonatal clinicians. We started with one ventilator and a monitor. At 11/2 years we had acquired 5 ventilators and 4 monitors.

Benefits of PICU Severely ill or injured now can benefit form more specialized care. Pediatric resident and interns rotating through PICU Dissemination of knowledge and critical thinking – locally and internationally Missions – Cardiac surgeries, OMF, neurosurgery etc Local capacity expression

Challenges Equipment Supplies Training Motivation

Collaboration: no need for reinventing the wheel Universities in the East Africa sub-region Colleges – WACP/Ghana College of Physicians and Surgeons Eg. The first Emergency Medicine training in the W/A sub-region in Ghana Others PCCM: ? Support faculties with training, equipment sourcing and provision Openpediatrics initiative

Role of Little Steps Fundraising tool Initiated by doctors and nurses Facility supported Engaging the community Local and international

Acknowledgement Africa Paediatric Fellowship Programme Red Cross War Memorial Children’s Hospital University of Cape Town Prof. Andrew Argent Boston Children’s Hospital