Care of sick newborns at KNH Fred Were EBS UON 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 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

Background trends 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

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 Cohort 7500 lbs 750 will require care 75 will need Level III Surrounding Facilities 50,000 lbs 5000 will need care 500 need Level III

The projected complication rates (Prematurity, Asphyxia rates e t c) This will lead to requirement of more NICU space The 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 KNH (Low Resource Settings) Low complications rates Prematurity/LBW <5% Asphyxia <1% Need 1 NICU bed/2000live birth High complications rates Prematurity/LBW rates >10% 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 Organization LEVEL Type of Care Venue I (Nursery) Short term observation and final convulscence Within maternity unit II (Special Care) Cardio-respiratory monitoring Intermediate interventions In the NBU III (Intensive care) Cardio-respiratory support Intensive observations Complicated interventions In a specialized unit

The Modern Structure of NBS Bed distribution Option 1 All NICU beds have ventilators able to deliver CPAP 2-3 level II beds per ventilator bed Option 2 ½ 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 Upgrading towards meeting demand 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

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