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. 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

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
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

8. 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

9. 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)

10. 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

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
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

14. 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

15. 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

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 hr week
Mid level clinicians/nurses with working 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