One morning last week, Kisii Teaching and Referral Hospital received a distress call from doctors treating a patient who was in need of an urgent intensive care unit (ICU) admission.
The county’s largest public facility could not admit the patient as its six Intensive Care Unit (ICU) beds were all occupied.
A call was made to Kenyatta National Teaching and Referral Hospital; unfortunately, all the beds were occupied. The same case applied to Moi Teaching and Referral Hospital.
The family managed to secure space in a private hospital but had to pay through the nose.
“The only option left for us was to refer the patient to a nearby facility which has ICU beds. We called Kenyatta National Hospital and Moi Teaching and Referral Hospital. Luckily for the patient, Avenue Healthcare in Kisumu had an available bed and so we referred the patient to that facility,” Chief Executive Officer Enoch Ondari told the Saturday Nation.
This story is common across the country; the only difference is thousands of such patients never make it to such facilities.
In the past, many patients in need of Intensive Care Unit services in public hospitals have had to die in the line after waiting for long hours to be attended to, or have been forced to cough up millions of shillings for the same in private hospitals.
Recently, a patient died while waiting for a bed at the packed KNH ICU, which has only 31 ICU beds, all of which were occupied at the time.
ICU bed shortage is a daily problem that leads to delayed treatment for those with an extended waiting time. And when one accesses the very few facilities, they charge an arm and a leg.
Public hospitals charge Sh5,000 while private hospitals charge as much as Sh576,000 in 24 hours, a price prohibitive even for the wealthy.
Mr Alex Madaga, for instance, waited for 18 hours to access treatment in the ICU at KNH. This demonstrated how many Kenyans are on the receiving end of a severely overstretched public healthcare system.
ALEX MADAGA DIES
How fast intensive care is given, especially after trauma, which is common in cases of near-fatal accidents such as falls and road crashes, determines whether one survives or not.
Mr Madaga, 37, sustained serious head injuries in a road accident that left him unconscious. He was also unable to breathe on his own.
He was referred from Kikuyu Hospital. The patient had been taken to two private hospitals that asked for a down payment of Sh200,000 before treatment. His family could not raise the cash.
After 18 agonising hours in an ambulance, he succumbed to his injuries shortly after being admitted to the ICU ward in KNH on October 9, 2015.
Cases of patients dying while waiting for ICU space brings to the fore the dire state of the country's healthcare. This could be a snapshot of the full image of the country’s ailing health sector.
The ICU is an unfamiliar, difficult environment that often becomes the centre of people’s lives as they wait desperately for any sign of change or progress in the health of their loved ones.
Yet statistics indicate that facilities offering this most critical of services to the gravely ill are seriously lacking in the country.
There are only 106 properly equipped ICU beds in all public hospitals across the country to serve a population of 51 million Kenyans but only 42 of them can take care of patients whose lives are at risk.
At Kenyatta National Hospital (top referral hospital in East Africa), there are 31 ICU beds and six at Moi Teaching and Referral Hospital. At Jaramogi Oginga Odinga Teaching and Referral Hospital, only eight ICU beds are working while six are under construction.
Coast General Hospital has eight, Machakos Level Five Hospital has three, Kijabe AIC Hospital (five) while Kilifi has 20 ICU beds under construction with Salgaa — World Bank Project five ICU bed facility under construction.
Nyeri Level Five Hospital has four ICU beds while Nakuru has eight. Kakamega has 12 and only four are operational while Thika Level Five has one.
However, the situation is worse in counties without referral hospitals. Most of them do not have ICU services and, in cases of emergency, the patients have to be flown or driven for kilometres to access the services.
In Migori, Siaya, Nyamira, Vihiga, Bungoma and Trans Nzoia, there are no ICU services in all the public hospitals. In Homa Bay, there are two ICU beds but none is operational.
Dr Ouma Oluga, who practises at KNH, said the situation is alarming and the capacity of the hospital to provide specialised care is limited and cannot meet the demand.
“If one needs an ICU bed at KNH or any public hospital, one has one in a million chances of getting it and a number of patients get average care at best,” he said.
He said a total of 80 patients in the country need specialised care at KNH but only 31 beds are available, which means some get the services at private hospitals.
However, this is going to be a thing of the past as hospitals and counties work towards increasing their bed capacity for specialised services.
KNH is set to expand its Intensive Care Unit (ICU) bed capacity by 24 in a new construction project.
The project, which is expected to be completed in two years, marks a major effort by the facility to address the ICU bed shortage.
Acting Chief Executive Officer Thomas Mutie said the project will cost Sh2.7 billion.
“We will source for the funds from the government as well as development partners and well-wishers in order to cater for the project,” Dr Mutie said.
The unit will also have a six-bed high dependency unit.
The Moi Teaching and Referral Hospital has also increased its ICU bed capacity to 20 from six.
Chief Executive Officer Wilson Aruasa on Friday said the new ICU includes four units put up by the Uasin Gishu government.
He said they have state-of-the-art machines that will handle patients effectively.
“We are developing this hospital for the future so it continues offering the best services to patients,” Mr Aruasa said.
According to emergency care policy in the country, all patients should be given care, lack of money notwithstanding; but inasmuch as these sentiments are good, it is unfortunate that they are not in line with the realities of healthcare economics.
While hospitals would love to help and indeed do so most of the time, it is not a sustainable approach. Thus, hospital administrators come up with policies to safeguard their financial position.
Dr Edward Omete of KNH and healthcare administration said the low number of intensive care and high dependency unit beds in the country is not by choice.
“ICU operations are not like ordinary healthcare services. They are highly specialised, highly sophisticated and use highly trained staff. They also run on a strict 24-hour basis. Their staffing ratio for nurses and doctors to patients is the highest,” he said.
SOLUTION TO CRISES
Doctor's review is in hours, sometimes even thrice a day, and involves multiple specialists.
He added: “To make matters worse, no definite prognostic timelines are given for when a patient will get out of the ICU bed. Because of this, intensive care usually ends up being an expensive affair, with bills running into hundreds of thousands or millions in just a few days. This places us in a moral and administrative quagmire.”
He said that to address situations that require ICU services, a breakdown of the top 10 causes of admission into ICU is the first step.
The next step should be how to stop avoidable causes, like trauma from road traffic accidents and infections.
“The public’s role is lobbying for road safety reforms and striving to have medical insurance; healthcare is an expensive affair,” he said.
Critical care encompasses not just ICU per se, but also High Dependency Units; Kidney Dialysis Units; Operating Theatres; Burn Units; Cardiology Units and Stroke Units.
Each ICU bed should have a complete set of associated monitoring equipment; suction apparatus; infusion pumps; and mechanical ventilator, nurses, and doctors trained in critical care.
Another major problem is lack of staff trained in critical care, especially in public health facilities.
A good unit should have between five and 10 beds for it to be economically viable, which means that it should be able to pay for its own maintenance and meet the costs of paying the staff.
Using a rough estimate of five ICU nurses per one ICU bed and one ICU doctor per five ICU beds, each working 12-hour shifts all year round, one could calculate the numbers required depending on the proposed ICU size.
These individuals are entitled to leave and time-off just like other workers.
The minimum cost of certain ICU equipment is as follows: Bed Sh500,000, heart monitor Sh750,000, mechanical ventilator Sh1 million and blood gas machine Sh250,000.
All this equipment come with consumables like dressing and requires regular maintenance.
“It is very expensive to put up an ICU unit which costs at least Sh9 million per piece. This is why it is very costly for level five or county hospitals to construct a unit,” Dr Mutie said.