- Email: [email protected]
The history of critical care in Kenya
Journal Pre-proof The history of critical care in Kenya
Wangari Waweru-Siika, Vitalis Mung'ayi, David Misango, Andrea Mogi, Allan Kisia, Zipporah Ngumi PII:
S0883-9441(19)30940-2
DOI:
https://doi.org/10.1016/j.jcrc.2019.09.021
Reference:
YJCRC 53390
To appear in:
Journal of Critical Care
Please cite this article as: W. Waweru-Siika, V. Mung'ayi, D. Misango, et al., The history of critical care in Kenya, Journal of Critical Care(2019), https://doi.org/10.1016/ j.jcrc.2019.09.021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof The History of Critical Care in Kenya Wangari Waweru-Siika1,* [email protected], Vitalis Mung’ayi1, David Misango1, Andrea Mogi2, Allan Kisia1, Zipporah Ngumi3 1
Department of Anaesthesia, Aga Khan University, Nairobi Department of Medicine, Kenyatta National Hospital, Nairobi 3 Department of Anaesthesia, University of Nairobi 2
*
Corresponding author at: Department of Anaesthesia, Aga Khan University, P.O. Box 30270, Nairobi, Kenya.
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Author Declaration We confirm that there are no known conflicts of interest associated with this publication and that there has been no financial support for this work. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We understand that the corresponding author is the sole contact for the editorial process (including Editorial Manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the corresponding author and which has been configured to accept email from [email protected]
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Signed by all authors on the 15th September 2019 as follows: Dr. Wangari Waweru-Siika Professor Vitalis Mung’ayi
Dr. David Misango
Mr. Andrea Mogi
Dr. Allan Kisia
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Professor Zipporah Ngumi Abstract Critical care is a young specialty in Kenya. From its humble beginnings in the 1960s to present day Kenya, the bulk of this service has largely been provided by anaesthetists. We provide a detailed account of the growth and development of this specialty in our country, the attempts made by our people to grow this service within our borders and the vital role our international partners have played throughout this process. We also share a selection of our successes over the years, the challenges we have faced and our aspirations as we look to the future.
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The birth of critical care in Kenya In 1950s Kenya, the third polio outbreak in our history reached epidemic proportions[1, 2]. Armed with a cuirasse and sheer determination, a British anaesthetist at the Respiratory Unit of the then King George Hospital dedicated two ward beds to the provision of a rudimentary form of respiratory support, and critical care in Kenya was born.
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In subsequent years, the Respiratory Unit, later renamed the Infectious Diseases Hospital (IDH), increasingly provided invasive ventilation to a growing number of polio victims, with varying degrees of success. [3-5] In the 1960s, IDH became home to the only haemodialysis machine in East and Central Africa, a donation from the family of a South African expatriate who had succumbed to the complications of renal failure while living in Kenya.[6] The first patient to benefit from it was flown in from Uganda specifically for this service and is still alive today.
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Recognising the need for a coordinated critical care service, the Kenya Government in collaboration with the Japanese International Cooperation Agency (JICA), established a dedicated 6-bed Intensive Care Unit (ICU) at the King George Hospital in 1971. [3, 7] Later renamed the Kenyatta National Hospital (KNH), this institution is our largest public, tertiary institution, and home to our first medical school, the University of Nairobi College of Health Sciences (Figure 1, 2). The arrival of the Japanese raised the bar for critical care in Kenya, with better equipment, improved monitoring standards, and the ability to perform blood gas analysis for the very first time. The introduction of a formal critical care service at that point in our history was timely, as there then followed an outbreak of laryngotracheobronchitis, many of whom were successfully managed in this unit. [8, 9]
The dawn of critical care nursing Lack of local capacity to sustain a formal critical care service when it was first launched led to Japanese anaesthetists, surgeons and critical care nurses having to provide the bulk of the skilled labour in our fledgling ICU, as capacity building began in earnest. Critical care nursing in Kenya therefore has its genesis in the on-the-job trainings that our nurses received from the Japanese in the 1970s. Initially lasting only three-months,
Journal Pre-proof these trainings were extended to six months, and later to nine. Critical care training programmes for Kenyan nurses were later established in Japan and Madras, India.[10]
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In 1975, the Kenya Medical Training College (KMTC) in Nairobi launched a one-year critical care nursing diploma programme, advertising for its first class of 12. Unfortunately, this course was not well understood outside of KNH, and only six nurses applied. With time however, demand increased and the programme grew, expanding its intake over the years. Meanwhile, at the privately-owned Nairobi Hospital, the Cecily McDonnell School of Nursing began to offer nine-month long trainings in 1996. In spite of this however, these programmes could not meet the needs of a rapidly expanding critical care service at KNH, and, in 1997, KNH began its own training programme, selectively admitting its own nurses. Over time, as an increasing number of applications were received from other facilities in the country, and from as far as Rwanda and Zimbabwe, KNH opened its doors to nurses from outside the institution. Other centres then emerged that offered critical care nursing at diploma level, including the Cecily McDonnell School of Nursing in 2009, the Moi Teaching and Referral Hospital in 2012 and most recently, the Machakos Medical Training College (MTC) in 2018. A 2015 survey found there to be a total of 414 nurses in the 21 ICUs in Kenya, 204 (49%) of whom have formal critical care training.
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The rise of the intensivist From the iron lungs of IDH to present day Kenya, anaesthetists have doubled up as ‘the physicians for the ICU’. The perception that anaesthesia training equipped one sufficiently to take care of the critically ill, combined with transferable skills in ventilation, airway management and the insertion of invasive lines, led many to assume this role with ease. A 2015 survey of 21 ICUs in Kenya identified anaesthesiologists as the most common primary care clinicians in 47% of units surveyed[7].
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Following the departure of the Japanese in the ‘70s, a Ghanaian anaesthetist, Professor Emmanuel Ayim, successfully took over the leadership of the KNH ICU.[11, 12] It then became apparent to many that intensive post-operative monitoring and organ support following complex procedures was possible locally, and that the odds of achieving good outcomes were a lot better as a result. A series of firsts then followed that we credit to this new-found confidence: In 1973, the cardiac catheterization lab in KNH became operational. That year, the first patient to undergo open heart surgery in Kenya was nursed in the KNH ICU.[10] In 1979, the first separation of Siamese twins was carried out. And in 1980, Kenya celebrated her first kidney transplant, the first in East and Central Africa[13]. The fate of our landmark surgeries of the 70s and early 80s, and the remarkably good outcomes that were realized, rested heavily on the shoulders of anaesthetists as there were neither intensivists nor resident ICU doctors by then. We therefore credit the bulk of the progress made in critical care in Kenya over the years to the anaesthesiologists who trained abroad in the 70s and 80s on British Council scholarships, returning home thereafter to serve their people. Having been awarded
Journal Pre-proof fellowships in anaesthesia and critical care in the United Kingdom, they formed the bedrock of early critical care in Kenya when they returned. The first Kenyan to receive this training was a cardiac anaesthetist, Dr. Alan Kisia, who is still in active service.
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The introduction of a Master of Medicine programme in Anaesthesia in 1979 was a pivotal moment for critical care in Kenya. For the first time, Kenya had the potential to provide a pool of anaesthetists to meet local demand, providing the necessary workforce to run our ICUs.[11] It was not until the move to have critical care recognised as a specialty gained traction worldwide, that the first Kenyan, Dr. Vitalis Mung’ayi, underwent a period of dedicated training in Tel Aviv in 2002 courtesy of MASHAV, Israel’s Agency for International Development Cooperation[14]. Since then, thanks to the lobbying and support of the older generation of anaesthetists, more Kenyans have gone on to receive formal critical care training. The majority of these have been anaesthetists, as the World Federation of Societies of Anaesthesiologists (WFSA) has played a crucial role in sourcing training opportunities for them from amongst its membership.
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In recent years, specialties such as paediatrics, surgery and medicine have increasingly ventured into the world of critical care sub-specialty training. As a result, the Critical Care Society of Kenya (CCSK) emerged as an independent society in 2012, out of the shadow of the mother society, the Kenya Society of Anaesthesiologists (KSA).[15] KSA had been instrumental over the years in overseeing training standards in both anaesthesia and critical care, but its remit did not extend beyond the anaesthesia fraternity. The vision of CCSK therefore was to provide a vehicle through which intensivists who were not necessarily anaesthetists could interact, to advance the practice of critical care nationally. Critical care was however only recognized as a distinct specialty by the Medical Practitioners and Dentists Board in 2017, and even then, only as a sub-specialty of anaesthesia. Our numbers have grown slowly over the years, as the lack of local sub-specialty training programmes has meant leaving Kenya for extended periods to receive training in the UK, Israel or South Africa, an option that is untenable for many.
Supporting disciplines During the period in our history when intensivists did not exist in Kenya, the involvement of other specialists in the care of the critically ill was crucial. Cardiothoracic surgeons such as Professor Edward Knight from Jamaica who performed Kenya’s first open heart surgery, and Professor Fujita from Japan who led the JICA team, played a pivotal role in guiding the post-operative management of surgical patients in the KNH ICU.[10] This practice gave rise to the early acceptance of the need for a multidisciplinary approach to critical care in this country. Nephrologists, cardiologists and even general physicians were regularly consulted and depended on to guide care. Many continue to do so to this day. The concept of the intensivist as an independent practitioner capable of guiding the care of the critically ill has yet to gain widespread acceptance in Kenya. Indeed, many here still view their role as merely as that of ‘managing the ventilator’.
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Radiology and microbiology warrant special mention as services whose presence contributed significantly to the growth and development of critical care in Kenya. In 1975, a British radiologist, Professor Leslie Robert Whittaker, was appointed Head of Diagnostic Radiology at the University of Nairobi Medical School, overseeing the radiology service at the Kenyatta National Hospital. [16] Under his watch and with equipment donated by the Japanese, a portable X-ray service was provided for patients in critical care. The machines then were cumbersome to use however, and required manual development of films, a process that took up to 20 minutes to complete. They were eventually replaced by automatic Kodak® processors initially, and later by digital X-rays. In 1979, ultrasound technology was introduced at the MP Shah Hospital in Nairobi. Equipment at the time was bulky, and even the critically ill had to be moved to the radiology department for this service. Finally, the first CT scan machine became available at the Nairobi Hospital in the mid 1980s through the efforts of an American cardiologist, Dr. David Silverstein. Dubbed the ‘father of cardiology’ in Kenya, he had previously served as head of the first cardiac catherization unit when it was opened in KNH in 1973.[17]
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At the establishment of the KNH ICU, medical microbiologists then were predominantly veterinarians. In 1997, a clinical microbiologist from India, Prof Gunthuru Revathi joined the institution and helped to set up a lab within the KNH ICU. Two technologists were stationed in this satellite lab, predominantly to provide an emergency chemistry service, significantly shortening the turnaround time for samples drawn from the critically ill. The team however faced numerous challenges in these formative years, including a recurrent shortage of reagents, blood culture bottles as well as antibiotic discs for susceptibility testing.
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The resource challenge The availability, quality and functionality of the equipment available for critical care in Kenya has greatly improved over time. Nevertheless, up until the early 2000s, our equipment was still very basic and its availability limited. Our first positive pressure ventilators, the Radcliffe and Engstrom respirators, gave way to the Acoma 1000®, a basic but hardy workhorse that was cost-effective to use in this low-resource setting. Single use endotracheal tubes were not available until 2002, and we cleaned and reused what we had; this is no longer the case. For years, extubation readiness was assessed using Wright’s respirometer. Pulse oximeters were reserved for children and cardiac patients as their availability was limited; these now form part of our minimum monitoring standards. Arterial lines required bulky equipment and a specially trained technician to set up, and their use was restricted to cardiac surgery patients; arterial lines are now a 10-minute procedure performed easily by our junior doctors on a broad variety of patients. Many institutions derived oxygen from cylinders, and critical care was dogged by the recurrent problem of erratic oxygen supplies, requiring that patients be transferred to neighbouring facilities whenever supplies ran low. Bedside renal replacement therapy was not available in many facilities, necessitating perilous transfers to the renal unit and back whenever this therapy was prescribed; haemodialysis machines currently exist in some ICUs, including those that allow Continuous Renal Replacement Therapy (CRRT).
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The resilience of our colleagues in the face of seemingly insurmountable challenges is noteworthy. In 1998, our only other national hospital, the Moi Teaching and Referral Hospital, was elevated to national referral status. With this development, and as home to our second medical school, the Moi University School of Medicine, a huge influx of patients occurred at a time when the facility was ill-equipped to cope with the sudden rise in the demand for an ICU service. In 2005, a critical care bed was set up in the Post Anaesthesia Care Unit (PACU) by the anaesthetists there, to cater specifically for highrisk surgical patients. Respiratory support was not provided however, due to resourcelimitation. Nevertheless, from these humble beginnings came many a success story, from the patient with critical mitral stenosis in pregnancy for whom a safe, painless delivery was provided, to the child who had a hypoxic cardiac arrest on arrival who was successfully resuscitated, extubated after 36 hours, and discharged home following an uneventful recovery. It was not until 2006 that a dedicated 6-bed ICU was finally opened at MTRH following the intervention of an American anaesthetist, Professor Dennis Wagner. Sadly however, as the donated equipment had already been in use for extended periods prior to its arrival, frequent breakdowns were common and most were eventually grounded.
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While still insufficient to meet the needs of a growing populace, the number of critical care beds in Kenya has grown steadily over the years, as public, private and mission facilities have aspired to provide critical care services within their institutions (Figure 3). In 2014, the Ministry of Health launched the Managed Equipment Service (MES), a turnkey project whose vision was to boost ICU bed capacity in Kenya, to meet the needs of a growing populace. Public outcry in 2015 following the tragic death of a young man whose family could not secure a critical care bed in any of the four facilities they approached underscored the need for a government-led solution to this problem.[18] As the MES project began, a 2015 survey identified only 21 functional ICUs countrywide, a total bed capacity of 130 for 47.2 million Kenyans or 0.3 beds per 100,000 population[7]. In addition, while the reported availability of ICU equipment, essential drugs and diagnostic support ranged from over 95% in private and mission hospitals, this was only 60-80% in government facilities. By 2016, the MES had given rise to seven new ICUs, the bed capacity at MTRH had grown to 24 and KNH’s critical care bed capacity had risen to 71, the highest of a single facility in this country (Figure 4). The greatest challenge to the success of the MES initiative however has been the lack of the skilled human resource required for the provision of a sustainable critical care service.
Critical care processes and outcomes As best practice evolves worldwide, so too has the practice of critical care in Kenya. Until 2002, protocolised care was unheard of, and the introduction of critical care protocols at the Mater Misericordiae Hospital in Nairobi was revolutionary[19]. Prior to this, we intubated everyone nasotracheally, paralysed and sedated all intubated patients, and did not consider tracheostomies any earlier than Day 21; now we offer light sedation, avoid nasal tubes altogether and consider tracheostomies a lot
Journal Pre-proof earlier[20-22]. The introduction of opioid infusions for the sedation of non-cardiac patients was met with resistance when it was first suggested, but is now commonplace. Bolus nasogastric (NG) feeding of intubated patients was universally performed; now many units have enteral pumps for continuous NG feeding[23]. The changes have been many and varied over the years, and illustrate our ability to move with the times in an effort to provide evidence-based critical care[24, 25]. Where facilities have not adopted evidence-based care in this country, this has largely been due to resource-constraints at institutional level.
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Where resources are limited, stringent criteria for bed allocation become necessary. As such, whenever a critical care bed is requested in our public ICUs, a triage process begins that limits admission to those patients deemed likely to benefit from this limited resource, as there are often multiple patients competing for the same bed. Until the widespread availability of antiretroviral agents (ARVs) for instance, HIVinfected patients were not offered a critical care bed, as mortality was certain even with aggressive interventions. Even with improved outcomes with the introduction of PEPFAR funding in 2004, the unwritten ceiling of care for those admitted with Pneumocystis Carinii Pneumonia (PCP) was non-invasive ventilation (NIV), as it was widely believed that it would be impossible to liberate them from the ventilator if they were ever intubated. On the other hand, in spite of robust evidence that poor outcomes are inevitable in certain patient populations, our practice has been hampered by the lack of a legislative framework to guide the withholding or withdrawing of intensive care. ‘Minimal support’ for confirmed brain death for instance, rather than complete withdrawal of intensive care, has been practiced for many years in Kenya, as our laws do not recognise brain death as actual death[26]. The first institution to formulate a written document defining the ceiling of care for individual critical care patients in Kenya was the Aga Khan University Hospital, Nairobi, in 2014. The Change of Goals of Care form as it is called outlines the elements of ongoing critical care to include, and allows for a ceiling of care to be defined, including the option not to resuscitate in the event of a cardiac arrest. To date, very few ICUs in Kenya have such a policy. Nevertheless, even at this institution, de-escalation of care is not performed, even in the face of medical futility. Despite the presence of a growing number of intensivists in Kenya, the introduction of evidence-based practice and the expansion of critical care capacity, ICU outcomes in our public facilities had not been analysed until a study from MTRH reported a mortality rate of 54%, significantly higher than that in any other resource-limited country[27]. Outcomes in mission and private facility ICUs in Kenya on the other hand were postulated to be better as they are better resourced, and also because they serve a segment of the population that has the wherewithal to seek specialist intervention early. A 2016 study from Tenwek hospital, a mission facility in the south west of Kenya, confirmed this, reporting a crude ICU mortality rate of only 26%. The high mortality in our public facilities is likely multifactorial. Resource-limitation remains the most important factor, as it contributes to delays in diagnosis, delayed interventions and sub-optimal care. Other reasons include late presentation, late referral to critical care specialists, delayed admissions due to shortages of ICU beds and inadequate stabilisation before transfer.
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In spite of numerous challenges, Kenyan intensivists have contributed to the development of new knowledge over the years through collaborative research with partners from Europe and North America. We have shared our experiences and our research with the international community through our participation in working groups of professional societies, and the dissemination of our work in peer-reviewed journals[26-33]. Sustained quality improvement efforts and focused critical care research however have been crippled by the paucity of local data to guide our practice, hampered in turn by the lack of an electronic critical care database and the shortage of research funding. We remain hopeful however that as we gain greater visibility in the world of critical care, that we will find other partners willing to walk this journey with us towards improving critical care and critical care outcomes in Kenya.
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Acknowledgements The authors wish to thank Dr. Saleem Malik, Founding Chair, Department of Radiology, Aga Khan University Nairobi, for providing us with information on the history of radiology, and Prof Revathi, Clinical Microbiologist, Aga Khan University Nairobi for information on the history of microbiology. We also wish to thank Gakenia Siika for helping us generate a map of ICUs in Kenya.
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Anaesthetists, R.C.o., Criteria for Honours, Awards and Prizes. 2019. https://www.ncbi.nlm.nih.gov/pubmed/6995099, The First Renal Transplant in Kenya. https://mfa.gov.il/MFA/MASHAV/ABOUTMASHAV/Pages/default.aspx. The Critical Care Society of Kenya. Whittaker, N., Leslie Robert Whittaker. BMJ : British Medical Journal, 2015. 350: p. h1016. Chicago, T.U.o., Medical and Biological Sciences Alumni Association. E, K., Ambulance Patient Alex Magada Dies at KNH. Daily Nation, 2015. Chang SY, J.S.J., Martin GS. , Protocols in the management of critical illness. . Critical Care 2012. 16:306. De Leyn P, B.L., Delcroix M, Depuydt P, Lauwers G, Sokolov Y, Van Meerhaeghe A, Van Schil P., Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. Tracheotomy: clinical review and guidelines. . Eur J Cardiothorac Surg. , 2007. Sep;32(3):412-21. Epub 2007 Jun 27. Fassoulaki A, P.P., Prolonged nasotracheal intubation and its association with inflammation of paranasal sinuses. Anesth Analg. , 1989. Jul;69(1):50-2. Hebert PC, W.G., Blajchman MA, Marshall J, Martin C, Pagliarello G, and S.I. Tweeddale M, Yetisir E: Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. , A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. . N Engl J Med 1999. 340:409-417. Heyland DK, D.R., Drover JW, Gramlich L, Dodek P; , Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. . JPEN J Parenter Enteral Nutr. , 2003. Sep-Oct;27(5):355-73. Network, T.A.R.D.S., Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. . N Engl J Med 2000. 342:1301-1308. Rivers E, N.g.B., Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: , Early goal-directed therapy in the treatment of severe sepsis and septic shock. . N Engl J Med 2001, , 2001. 345:1368-1377. Waweru-Siika, W., et al., Brain death determination: the imperative for policy and legal initiatives in Sub-Saharan Africa. Global Public Health, 2017. 12(5): p. 589-600. Lalani H.S, W.W.-S., et al, Intensive Care Outcomes and Mortality Prediction at a National Referral Hospital in Western Kenya. Annals of the American Thoracic Society, 2018. 15(11): p. 1336-1343. Lalani, H.S., W. Waweru-Siika, and P.S. Kussin, Reply: Critical Care in SubSaharan Africa: Is It Ready for Prime Time? Annals of the American Thoracic Society, 2019. 16(1): p. 157-158. Misango, D., et al., Haemodynamic assessment and support in sepsis and septic shock in resource-limited settings. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2017. 111(11): p. 483-489. Shrestha, G.S., et al., International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries. Lancet Infect Dis, 2017. 17(9): p. 893-895.
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Journal Pre-proof The History of Critical Care in Kenya
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Figure 1. Kenyatta National Hospital
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Figure 2. Kenyatta National Hospital ICU
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Figure 3. Distribution of ICUs in Kenya
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Key: AKUHN Aga Khan University Hospital, Nairobi CPGH, Coast Provincial General Hospital, Nairobi HBTRH, Homa Bay Teaching and Referral Hospital JOOTRH, Jaramogi Oginga Odinga Teaching and Referral Hospital MTRH, Moi Teaching and Referral Hospital
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Key: MES, Managed Equipment Service
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Figure 4. Machakos County Hospital ICU, Established Under the MES Project
Journal Pre-proof The History of Critical Care in Kenya
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Highlights The growth and development of critical care in Kenya has largely been as a result of the efforts of anesthetists International partnerships have played a significant role in the expansion of critical care services in Kenya Although the specialty has faced numerous challenges over the years, its presence has provided support to other specialties, enabling them to achieve more than was previously thought possible The future of critical care in Kenya is bright but its full impact will require new partnerships to help it achieve its full potential
Wangari Waweru-Siika, Vitalis Mung'ayi, David Misango, Andrea Mogi, Allan Kisia, Zipporah Ngumi PII:
S0883-9441(19)30940-2
DOI:
https://doi.org/10.1016/j.jcrc.2019.09.021
Reference:
YJCRC 53390
To appear in:
Journal of Critical Care
Please cite this article as: W. Waweru-Siika, V. Mung'ayi, D. Misango, et al., The history of critical care in Kenya, Journal of Critical Care(2019), https://doi.org/10.1016/ j.jcrc.2019.09.021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof The History of Critical Care in Kenya Wangari Waweru-Siika1,* [email protected], Vitalis Mung’ayi1, David Misango1, Andrea Mogi2, Allan Kisia1, Zipporah Ngumi3 1
Department of Anaesthesia, Aga Khan University, Nairobi Department of Medicine, Kenyatta National Hospital, Nairobi 3 Department of Anaesthesia, University of Nairobi 2
*
Corresponding author at: Department of Anaesthesia, Aga Khan University, P.O. Box 30270, Nairobi, Kenya.
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Author Declaration We confirm that there are no known conflicts of interest associated with this publication and that there has been no financial support for this work. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We understand that the corresponding author is the sole contact for the editorial process (including Editorial Manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the corresponding author and which has been configured to accept email from [email protected]
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Signed by all authors on the 15th September 2019 as follows: Dr. Wangari Waweru-Siika Professor Vitalis Mung’ayi
Dr. David Misango
Mr. Andrea Mogi
Dr. Allan Kisia
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Professor Zipporah Ngumi Abstract Critical care is a young specialty in Kenya. From its humble beginnings in the 1960s to present day Kenya, the bulk of this service has largely been provided by anaesthetists. We provide a detailed account of the growth and development of this specialty in our country, the attempts made by our people to grow this service within our borders and the vital role our international partners have played throughout this process. We also share a selection of our successes over the years, the challenges we have faced and our aspirations as we look to the future.
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The birth of critical care in Kenya In 1950s Kenya, the third polio outbreak in our history reached epidemic proportions[1, 2]. Armed with a cuirasse and sheer determination, a British anaesthetist at the Respiratory Unit of the then King George Hospital dedicated two ward beds to the provision of a rudimentary form of respiratory support, and critical care in Kenya was born.
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In subsequent years, the Respiratory Unit, later renamed the Infectious Diseases Hospital (IDH), increasingly provided invasive ventilation to a growing number of polio victims, with varying degrees of success. [3-5] In the 1960s, IDH became home to the only haemodialysis machine in East and Central Africa, a donation from the family of a South African expatriate who had succumbed to the complications of renal failure while living in Kenya.[6] The first patient to benefit from it was flown in from Uganda specifically for this service and is still alive today.
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Recognising the need for a coordinated critical care service, the Kenya Government in collaboration with the Japanese International Cooperation Agency (JICA), established a dedicated 6-bed Intensive Care Unit (ICU) at the King George Hospital in 1971. [3, 7] Later renamed the Kenyatta National Hospital (KNH), this institution is our largest public, tertiary institution, and home to our first medical school, the University of Nairobi College of Health Sciences (Figure 1, 2). The arrival of the Japanese raised the bar for critical care in Kenya, with better equipment, improved monitoring standards, and the ability to perform blood gas analysis for the very first time. The introduction of a formal critical care service at that point in our history was timely, as there then followed an outbreak of laryngotracheobronchitis, many of whom were successfully managed in this unit. [8, 9]
The dawn of critical care nursing Lack of local capacity to sustain a formal critical care service when it was first launched led to Japanese anaesthetists, surgeons and critical care nurses having to provide the bulk of the skilled labour in our fledgling ICU, as capacity building began in earnest. Critical care nursing in Kenya therefore has its genesis in the on-the-job trainings that our nurses received from the Japanese in the 1970s. Initially lasting only three-months,
Journal Pre-proof these trainings were extended to six months, and later to nine. Critical care training programmes for Kenyan nurses were later established in Japan and Madras, India.[10]
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In 1975, the Kenya Medical Training College (KMTC) in Nairobi launched a one-year critical care nursing diploma programme, advertising for its first class of 12. Unfortunately, this course was not well understood outside of KNH, and only six nurses applied. With time however, demand increased and the programme grew, expanding its intake over the years. Meanwhile, at the privately-owned Nairobi Hospital, the Cecily McDonnell School of Nursing began to offer nine-month long trainings in 1996. In spite of this however, these programmes could not meet the needs of a rapidly expanding critical care service at KNH, and, in 1997, KNH began its own training programme, selectively admitting its own nurses. Over time, as an increasing number of applications were received from other facilities in the country, and from as far as Rwanda and Zimbabwe, KNH opened its doors to nurses from outside the institution. Other centres then emerged that offered critical care nursing at diploma level, including the Cecily McDonnell School of Nursing in 2009, the Moi Teaching and Referral Hospital in 2012 and most recently, the Machakos Medical Training College (MTC) in 2018. A 2015 survey found there to be a total of 414 nurses in the 21 ICUs in Kenya, 204 (49%) of whom have formal critical care training.
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The rise of the intensivist From the iron lungs of IDH to present day Kenya, anaesthetists have doubled up as ‘the physicians for the ICU’. The perception that anaesthesia training equipped one sufficiently to take care of the critically ill, combined with transferable skills in ventilation, airway management and the insertion of invasive lines, led many to assume this role with ease. A 2015 survey of 21 ICUs in Kenya identified anaesthesiologists as the most common primary care clinicians in 47% of units surveyed[7].
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Following the departure of the Japanese in the ‘70s, a Ghanaian anaesthetist, Professor Emmanuel Ayim, successfully took over the leadership of the KNH ICU.[11, 12] It then became apparent to many that intensive post-operative monitoring and organ support following complex procedures was possible locally, and that the odds of achieving good outcomes were a lot better as a result. A series of firsts then followed that we credit to this new-found confidence: In 1973, the cardiac catheterization lab in KNH became operational. That year, the first patient to undergo open heart surgery in Kenya was nursed in the KNH ICU.[10] In 1979, the first separation of Siamese twins was carried out. And in 1980, Kenya celebrated her first kidney transplant, the first in East and Central Africa[13]. The fate of our landmark surgeries of the 70s and early 80s, and the remarkably good outcomes that were realized, rested heavily on the shoulders of anaesthetists as there were neither intensivists nor resident ICU doctors by then. We therefore credit the bulk of the progress made in critical care in Kenya over the years to the anaesthesiologists who trained abroad in the 70s and 80s on British Council scholarships, returning home thereafter to serve their people. Having been awarded
Journal Pre-proof fellowships in anaesthesia and critical care in the United Kingdom, they formed the bedrock of early critical care in Kenya when they returned. The first Kenyan to receive this training was a cardiac anaesthetist, Dr. Alan Kisia, who is still in active service.
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The introduction of a Master of Medicine programme in Anaesthesia in 1979 was a pivotal moment for critical care in Kenya. For the first time, Kenya had the potential to provide a pool of anaesthetists to meet local demand, providing the necessary workforce to run our ICUs.[11] It was not until the move to have critical care recognised as a specialty gained traction worldwide, that the first Kenyan, Dr. Vitalis Mung’ayi, underwent a period of dedicated training in Tel Aviv in 2002 courtesy of MASHAV, Israel’s Agency for International Development Cooperation[14]. Since then, thanks to the lobbying and support of the older generation of anaesthetists, more Kenyans have gone on to receive formal critical care training. The majority of these have been anaesthetists, as the World Federation of Societies of Anaesthesiologists (WFSA) has played a crucial role in sourcing training opportunities for them from amongst its membership.
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In recent years, specialties such as paediatrics, surgery and medicine have increasingly ventured into the world of critical care sub-specialty training. As a result, the Critical Care Society of Kenya (CCSK) emerged as an independent society in 2012, out of the shadow of the mother society, the Kenya Society of Anaesthesiologists (KSA).[15] KSA had been instrumental over the years in overseeing training standards in both anaesthesia and critical care, but its remit did not extend beyond the anaesthesia fraternity. The vision of CCSK therefore was to provide a vehicle through which intensivists who were not necessarily anaesthetists could interact, to advance the practice of critical care nationally. Critical care was however only recognized as a distinct specialty by the Medical Practitioners and Dentists Board in 2017, and even then, only as a sub-specialty of anaesthesia. Our numbers have grown slowly over the years, as the lack of local sub-specialty training programmes has meant leaving Kenya for extended periods to receive training in the UK, Israel or South Africa, an option that is untenable for many.
Supporting disciplines During the period in our history when intensivists did not exist in Kenya, the involvement of other specialists in the care of the critically ill was crucial. Cardiothoracic surgeons such as Professor Edward Knight from Jamaica who performed Kenya’s first open heart surgery, and Professor Fujita from Japan who led the JICA team, played a pivotal role in guiding the post-operative management of surgical patients in the KNH ICU.[10] This practice gave rise to the early acceptance of the need for a multidisciplinary approach to critical care in this country. Nephrologists, cardiologists and even general physicians were regularly consulted and depended on to guide care. Many continue to do so to this day. The concept of the intensivist as an independent practitioner capable of guiding the care of the critically ill has yet to gain widespread acceptance in Kenya. Indeed, many here still view their role as merely as that of ‘managing the ventilator’.
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Radiology and microbiology warrant special mention as services whose presence contributed significantly to the growth and development of critical care in Kenya. In 1975, a British radiologist, Professor Leslie Robert Whittaker, was appointed Head of Diagnostic Radiology at the University of Nairobi Medical School, overseeing the radiology service at the Kenyatta National Hospital. [16] Under his watch and with equipment donated by the Japanese, a portable X-ray service was provided for patients in critical care. The machines then were cumbersome to use however, and required manual development of films, a process that took up to 20 minutes to complete. They were eventually replaced by automatic Kodak® processors initially, and later by digital X-rays. In 1979, ultrasound technology was introduced at the MP Shah Hospital in Nairobi. Equipment at the time was bulky, and even the critically ill had to be moved to the radiology department for this service. Finally, the first CT scan machine became available at the Nairobi Hospital in the mid 1980s through the efforts of an American cardiologist, Dr. David Silverstein. Dubbed the ‘father of cardiology’ in Kenya, he had previously served as head of the first cardiac catherization unit when it was opened in KNH in 1973.[17]
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At the establishment of the KNH ICU, medical microbiologists then were predominantly veterinarians. In 1997, a clinical microbiologist from India, Prof Gunthuru Revathi joined the institution and helped to set up a lab within the KNH ICU. Two technologists were stationed in this satellite lab, predominantly to provide an emergency chemistry service, significantly shortening the turnaround time for samples drawn from the critically ill. The team however faced numerous challenges in these formative years, including a recurrent shortage of reagents, blood culture bottles as well as antibiotic discs for susceptibility testing.
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The resource challenge The availability, quality and functionality of the equipment available for critical care in Kenya has greatly improved over time. Nevertheless, up until the early 2000s, our equipment was still very basic and its availability limited. Our first positive pressure ventilators, the Radcliffe and Engstrom respirators, gave way to the Acoma 1000®, a basic but hardy workhorse that was cost-effective to use in this low-resource setting. Single use endotracheal tubes were not available until 2002, and we cleaned and reused what we had; this is no longer the case. For years, extubation readiness was assessed using Wright’s respirometer. Pulse oximeters were reserved for children and cardiac patients as their availability was limited; these now form part of our minimum monitoring standards. Arterial lines required bulky equipment and a specially trained technician to set up, and their use was restricted to cardiac surgery patients; arterial lines are now a 10-minute procedure performed easily by our junior doctors on a broad variety of patients. Many institutions derived oxygen from cylinders, and critical care was dogged by the recurrent problem of erratic oxygen supplies, requiring that patients be transferred to neighbouring facilities whenever supplies ran low. Bedside renal replacement therapy was not available in many facilities, necessitating perilous transfers to the renal unit and back whenever this therapy was prescribed; haemodialysis machines currently exist in some ICUs, including those that allow Continuous Renal Replacement Therapy (CRRT).
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The resilience of our colleagues in the face of seemingly insurmountable challenges is noteworthy. In 1998, our only other national hospital, the Moi Teaching and Referral Hospital, was elevated to national referral status. With this development, and as home to our second medical school, the Moi University School of Medicine, a huge influx of patients occurred at a time when the facility was ill-equipped to cope with the sudden rise in the demand for an ICU service. In 2005, a critical care bed was set up in the Post Anaesthesia Care Unit (PACU) by the anaesthetists there, to cater specifically for highrisk surgical patients. Respiratory support was not provided however, due to resourcelimitation. Nevertheless, from these humble beginnings came many a success story, from the patient with critical mitral stenosis in pregnancy for whom a safe, painless delivery was provided, to the child who had a hypoxic cardiac arrest on arrival who was successfully resuscitated, extubated after 36 hours, and discharged home following an uneventful recovery. It was not until 2006 that a dedicated 6-bed ICU was finally opened at MTRH following the intervention of an American anaesthetist, Professor Dennis Wagner. Sadly however, as the donated equipment had already been in use for extended periods prior to its arrival, frequent breakdowns were common and most were eventually grounded.
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While still insufficient to meet the needs of a growing populace, the number of critical care beds in Kenya has grown steadily over the years, as public, private and mission facilities have aspired to provide critical care services within their institutions (Figure 3). In 2014, the Ministry of Health launched the Managed Equipment Service (MES), a turnkey project whose vision was to boost ICU bed capacity in Kenya, to meet the needs of a growing populace. Public outcry in 2015 following the tragic death of a young man whose family could not secure a critical care bed in any of the four facilities they approached underscored the need for a government-led solution to this problem.[18] As the MES project began, a 2015 survey identified only 21 functional ICUs countrywide, a total bed capacity of 130 for 47.2 million Kenyans or 0.3 beds per 100,000 population[7]. In addition, while the reported availability of ICU equipment, essential drugs and diagnostic support ranged from over 95% in private and mission hospitals, this was only 60-80% in government facilities. By 2016, the MES had given rise to seven new ICUs, the bed capacity at MTRH had grown to 24 and KNH’s critical care bed capacity had risen to 71, the highest of a single facility in this country (Figure 4). The greatest challenge to the success of the MES initiative however has been the lack of the skilled human resource required for the provision of a sustainable critical care service.
Critical care processes and outcomes As best practice evolves worldwide, so too has the practice of critical care in Kenya. Until 2002, protocolised care was unheard of, and the introduction of critical care protocols at the Mater Misericordiae Hospital in Nairobi was revolutionary[19]. Prior to this, we intubated everyone nasotracheally, paralysed and sedated all intubated patients, and did not consider tracheostomies any earlier than Day 21; now we offer light sedation, avoid nasal tubes altogether and consider tracheostomies a lot
Journal Pre-proof earlier[20-22]. The introduction of opioid infusions for the sedation of non-cardiac patients was met with resistance when it was first suggested, but is now commonplace. Bolus nasogastric (NG) feeding of intubated patients was universally performed; now many units have enteral pumps for continuous NG feeding[23]. The changes have been many and varied over the years, and illustrate our ability to move with the times in an effort to provide evidence-based critical care[24, 25]. Where facilities have not adopted evidence-based care in this country, this has largely been due to resource-constraints at institutional level.
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Where resources are limited, stringent criteria for bed allocation become necessary. As such, whenever a critical care bed is requested in our public ICUs, a triage process begins that limits admission to those patients deemed likely to benefit from this limited resource, as there are often multiple patients competing for the same bed. Until the widespread availability of antiretroviral agents (ARVs) for instance, HIVinfected patients were not offered a critical care bed, as mortality was certain even with aggressive interventions. Even with improved outcomes with the introduction of PEPFAR funding in 2004, the unwritten ceiling of care for those admitted with Pneumocystis Carinii Pneumonia (PCP) was non-invasive ventilation (NIV), as it was widely believed that it would be impossible to liberate them from the ventilator if they were ever intubated. On the other hand, in spite of robust evidence that poor outcomes are inevitable in certain patient populations, our practice has been hampered by the lack of a legislative framework to guide the withholding or withdrawing of intensive care. ‘Minimal support’ for confirmed brain death for instance, rather than complete withdrawal of intensive care, has been practiced for many years in Kenya, as our laws do not recognise brain death as actual death[26]. The first institution to formulate a written document defining the ceiling of care for individual critical care patients in Kenya was the Aga Khan University Hospital, Nairobi, in 2014. The Change of Goals of Care form as it is called outlines the elements of ongoing critical care to include, and allows for a ceiling of care to be defined, including the option not to resuscitate in the event of a cardiac arrest. To date, very few ICUs in Kenya have such a policy. Nevertheless, even at this institution, de-escalation of care is not performed, even in the face of medical futility. Despite the presence of a growing number of intensivists in Kenya, the introduction of evidence-based practice and the expansion of critical care capacity, ICU outcomes in our public facilities had not been analysed until a study from MTRH reported a mortality rate of 54%, significantly higher than that in any other resource-limited country[27]. Outcomes in mission and private facility ICUs in Kenya on the other hand were postulated to be better as they are better resourced, and also because they serve a segment of the population that has the wherewithal to seek specialist intervention early. A 2016 study from Tenwek hospital, a mission facility in the south west of Kenya, confirmed this, reporting a crude ICU mortality rate of only 26%. The high mortality in our public facilities is likely multifactorial. Resource-limitation remains the most important factor, as it contributes to delays in diagnosis, delayed interventions and sub-optimal care. Other reasons include late presentation, late referral to critical care specialists, delayed admissions due to shortages of ICU beds and inadequate stabilisation before transfer.
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In spite of numerous challenges, Kenyan intensivists have contributed to the development of new knowledge over the years through collaborative research with partners from Europe and North America. We have shared our experiences and our research with the international community through our participation in working groups of professional societies, and the dissemination of our work in peer-reviewed journals[26-33]. Sustained quality improvement efforts and focused critical care research however have been crippled by the paucity of local data to guide our practice, hampered in turn by the lack of an electronic critical care database and the shortage of research funding. We remain hopeful however that as we gain greater visibility in the world of critical care, that we will find other partners willing to walk this journey with us towards improving critical care and critical care outcomes in Kenya.
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Acknowledgements The authors wish to thank Dr. Saleem Malik, Founding Chair, Department of Radiology, Aga Khan University Nairobi, for providing us with information on the history of radiology, and Prof Revathi, Clinical Microbiologist, Aga Khan University Nairobi for information on the history of microbiology. We also wish to thank Gakenia Siika for helping us generate a map of ICUs in Kenya.
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Anaesthetists, R.C.o., Criteria for Honours, Awards and Prizes. 2019. https://www.ncbi.nlm.nih.gov/pubmed/6995099, The First Renal Transplant in Kenya. https://mfa.gov.il/MFA/MASHAV/ABOUTMASHAV/Pages/default.aspx. The Critical Care Society of Kenya. Whittaker, N., Leslie Robert Whittaker. BMJ : British Medical Journal, 2015. 350: p. h1016. Chicago, T.U.o., Medical and Biological Sciences Alumni Association. E, K., Ambulance Patient Alex Magada Dies at KNH. Daily Nation, 2015. Chang SY, J.S.J., Martin GS. , Protocols in the management of critical illness. . Critical Care 2012. 16:306. De Leyn P, B.L., Delcroix M, Depuydt P, Lauwers G, Sokolov Y, Van Meerhaeghe A, Van Schil P., Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. Tracheotomy: clinical review and guidelines. . Eur J Cardiothorac Surg. , 2007. Sep;32(3):412-21. Epub 2007 Jun 27. Fassoulaki A, P.P., Prolonged nasotracheal intubation and its association with inflammation of paranasal sinuses. Anesth Analg. , 1989. Jul;69(1):50-2. Hebert PC, W.G., Blajchman MA, Marshall J, Martin C, Pagliarello G, and S.I. Tweeddale M, Yetisir E: Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. , A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. . N Engl J Med 1999. 340:409-417. Heyland DK, D.R., Drover JW, Gramlich L, Dodek P; , Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. . JPEN J Parenter Enteral Nutr. , 2003. Sep-Oct;27(5):355-73. Network, T.A.R.D.S., Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. . N Engl J Med 2000. 342:1301-1308. Rivers E, N.g.B., Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: , Early goal-directed therapy in the treatment of severe sepsis and septic shock. . N Engl J Med 2001, , 2001. 345:1368-1377. Waweru-Siika, W., et al., Brain death determination: the imperative for policy and legal initiatives in Sub-Saharan Africa. Global Public Health, 2017. 12(5): p. 589-600. Lalani H.S, W.W.-S., et al, Intensive Care Outcomes and Mortality Prediction at a National Referral Hospital in Western Kenya. Annals of the American Thoracic Society, 2018. 15(11): p. 1336-1343. Lalani, H.S., W. Waweru-Siika, and P.S. Kussin, Reply: Critical Care in SubSaharan Africa: Is It Ready for Prime Time? Annals of the American Thoracic Society, 2019. 16(1): p. 157-158. Misango, D., et al., Haemodynamic assessment and support in sepsis and septic shock in resource-limited settings. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2017. 111(11): p. 483-489. Shrestha, G.S., et al., International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries. Lancet Infect Dis, 2017. 17(9): p. 893-895.
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Figure 1. Kenyatta National Hospital
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Figure 2. Kenyatta National Hospital ICU
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Figure 3. Distribution of ICUs in Kenya
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Key: AKUHN Aga Khan University Hospital, Nairobi CPGH, Coast Provincial General Hospital, Nairobi HBTRH, Homa Bay Teaching and Referral Hospital JOOTRH, Jaramogi Oginga Odinga Teaching and Referral Hospital MTRH, Moi Teaching and Referral Hospital
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Key: MES, Managed Equipment Service
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Figure 4. Machakos County Hospital ICU, Established Under the MES Project
Journal Pre-proof The History of Critical Care in Kenya
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Highlights The growth and development of critical care in Kenya has largely been as a result of the efforts of anesthetists International partnerships have played a significant role in the expansion of critical care services in Kenya Although the specialty has faced numerous challenges over the years, its presence has provided support to other specialties, enabling them to achieve more than was previously thought possible The future of critical care in Kenya is bright but its full impact will require new partnerships to help it achieve its full potential