1. 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

3. 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

4. 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.

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

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

7. 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

8. Facilities for critically ill

9. 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
12% Admissions/yr: 1900
 6% Admissions/yr: 2800
PEU stay > 2 days = % of all admissions
Mortality = %
KATH Performance Review, 2005, 2015

10. What do we need?

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

12. Intervention needed in PICU
Primary outcome
Total Gen ICU admission ( )
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%

13. Age classification

14. Reason for admission

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

16. 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)

17. 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,

18. 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

19. 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.

20. 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

21. Challenges
Equipment
Supplies
Training
Motivation

22. 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

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

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