Kenya: Medics Warn of a Health Crisis Over Limited ICU Beds

The meticulous five-minute process of a nurse donning a set of personal protective gear introduces us to the negative pressure isolation room at the Aga Khan University Hospital's (AKUH) Intensive Care Unit.

The intensive care nurse demonstrates the process of strapping on the gear used to by health workers who handle patients diagnosed with infectious diseases like Covid-19.

She starts by washing her hands before putting on headgear and shoe covers. She then disinfects her hands and straps on a surgical mask with a face shield.

PROTECTIVE GOWN

She peels of the manufacturer's wrapper from a protective gown which she slides on and secures tightly. A pair of gloves covers each side of the sleeves of the gown. The five-minute procedure happens inside an anti-chamber room.

We then proceed into the sophisticated room where a vital signs monitor used to read the patient's heart rate, blood pressure and oxygen saturation and multiple oxygen and vacuum ports are mounted onto the wall above the bed. The data from the monitor is relayed to a central monitor located outside the patient's room to reduce movement. By the bedside is a set of infusion pumps.

These, AKUH infectious diseases unit head Reena Shah explains, are used to accurately administer intravenous medication are set beside the patient's bed.

Above the infusion pumps are a pair of fluid pumps. Unlike the latter, infusion pumps are used to set syringes that carry medicines. Finally, a stethoscope hangs by the infusion pump's pole.

A fully operational dialysis machine is also set up on standby in case the patient suffers renal failure.

Finally, there is a portable ventilator stand next to the bed. A mechanical ventilator is a machine that's used to support patients with severe respiratory conditions that impact the lungs, including pneumonia.

VENTILATOR

Before a patient is placed on a ventilator, Prof Shah explains, anaesthetists perform a procedure called intubation which requires the patient to be sedated and given a muscle relaxant, before a tube is placed through the mouth and into the windpipe. The tube is then attached to the ventilator and medical staff can adjust the rate that it pushes air into the lungs and adjust the oxygen mix.

A fully equipped ICU isolation room like this one is not cheap to set up.

Unlike a standard ICU room which costs anywhere between Sh7 million and Sh8 million, patients with contagious airborne diseases such as tuberculosis, measles, chickenpox, Severe Acute Respiratory Syndrome (Sars-CoV), Middle East Respiratory Syndrome (Mers-CoV), influenza, and coronavirus disease 2019 (Covid-19) require to be isolated in negative pressure rooms to prevent cross-contamination.

It includes a ventilation that generates "negative pressure" (lower than that of the surroundings) to allow air to flow into the isolation room but not out (air will naturally flow from areas with higher pressure to areas with lower pressure) thereby preventing contaminated air from escaping.

"When people talk of ventilators alone I wonder what they are talking about. These machines do not exist in isolation," says Critical Society of Kenya Secretary-General Idris Chikophe.

So strained are ICU beds in the country that health workers are warning that some patients who may end up developing critical versions of Covid-19 may not be able to access an ICU.

ALREADY LIMPING

Before the global crisis even began, Kenya's health system was already limping with few doctors and nurses and even fewer hospital beds per capita. Of the 518 ICU beds, 87 per cent are currently occupied. To ease the pressure on public facilities, the Ministry of Health has directed that planned major surgeries which require patients to be put in the ICU should be suspended.

Most of these beds are in private hospitals in Nairobi and Mombasa. But even with 314 beds in 53 private hospitals, 182 are currently occupied. Further, a joint data by the Kenya Healthcare Federation and Critical Care Society show that there are only 259 functional ventilators and 140 of them are already being used to manage other critically ill patients.

"As it is, we can handle sporadic cases. However, if these numbers increase, we will not be able to manage them," said Dr Chikophe.

Health authorities around the world are trying to find ways to fill their hospitals with more ventilators to cope with increasing numbers of coronavirus patients. While the vast majority of people who catch the Covid-19 disease experience only mild symptoms, about six per cent need hospital care, with older patients at higher risk. Without access to ventilators, many patients may die. Health Cabinet Secretary Mutahi Kagwe said local manufacturers will begin producing personal protective equipment (PPEs) and ventilators.

"Our biggest problem is that some of these equipment are lying idle because of lack of personnel. We do not have enough ICU nurses. For instance, over the last three years more than 30 per cent of the counties have set up these equipment but most are lying dormant," added Dr Chikophe.

INTERNATIONAL STANDARDS

International standards require that Covid-19 patients are housed in separate quarantine wards which must have controlled airflow. However, the inadequacy of these facilities has compelled the government to transform existing wards in county hospitals and medical training colleges into isolation units. The Ministry of Health has also called on private hospitals with specialised ICU wards to help. Even as people are told to observe social distancing, wash their hands with water and soap, or use alcohol-based sanitisers, concerns have been raised over the country's preparedness to handle critical patients.

When the outbreak was reported in Africa, the World Health Organization (WHO) set out to help countries tighten loose ends by, for instance, assessing the continent's capacity to handle critical cases.

The evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of resources.

The WHO estimates that 40 per cent of patients will have a mild version of the disease, where treatment is a mostly supportive therapy for the symptoms which do not require inpatient care.

Another 40 per cent have a moderate version of the disease that may require inpatient care.

SEVERE VERSIONS

While these two sets of patients will recover, it is the 15 per cent who are estimated to develop severe versions and the five per cent who become critically ill that are causing the global panic.

These patients develop difficulty in breathing and require oxygen therapy among other interventions including mechanical ventilation.

In the US for instance, between 21 and 31 per cent of Covid-19 patients have required hospitalisation and five to 11 per cent have required intensive care.

Ventilators are one of the most important tools hospitals have for keeping Covid-19 patients in the most critical condition alive. The number of Covid-19 cases is growing at such a rapid pace that it is possible that many hospitals will not have enough ventilators available for the patients that need them. If this happens, patients who would otherwise survive could die.

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