Why ICUs in Uganda need help

It is terrifying to have to be admitted in the Intensive Care Unit (ICU). Though, the patient might have resigned to their fate by then, the patient’s beloved ones haven’t. They bite their nails and move around in anticipation while glancing through the unit’s windows hoping to see how their patient is fairing never mind that the windows are usually drawn. And all this tension is because the ICU is many times the patient’s last chance to survive. The mood in any such unit says it all - quiet and almost lifeless, the patients are not the kind to be seen by the faint-hearted, what with all the tubes usually attached to them.

Though there are different types of ICUs, the general ICU is at the centre of medicating patients with the most serious illnesses especially those affecting organs, all of which are life-threatening. Such patients also need constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions.

That is why, when Mulago Hospital’s general ICU was closed to patients that needed ventilators on October 29, over shortage of equipment, there was a loud public outcry. Later, there were reports that five people died before the unit was re-opened on November 2.

The reported closure of the unit was due to shortage of filters which protect patients from germs and infection coming from machines as well as making the air moist enough for the patient to take in.

Filters are used with ventilators - machines that help a patient breathe or do the actual breathing for them. Short of ventilators, the ICU doesn’t meet the crucial conditions by which it is defined.

The hospital administrators insist that the unit was not closed. They say that though the shortage of filters meant ventilation could not be done, patients could still be admitted and monitored. But the ICU medical staff says 99 per cent of their patients need ventilation so without filters, most patients couldn’t be helped. In fact, of all the ICUs directly under the Mulago Hospital docket, it is only the general ICU that has ventilators.

ICU history
Though the situation has now been rectified, shortage of filters was not all there was on the list of ICU troubles. The ICU beds are few and most of the equipment needs to be replaced. Started in the late 90s with a foreign donation, Mulago Hospital’s general ICU was initially run by a UK trained anaesthesiologist Dr Catherine Omaswa, who has since retired.

ICU components
The ICU is a 12-bed unit, its state since its establishment. It serves Mulago Hospital, which is a 1,500 bed national referral hospital, and Makerere University teaching hospital. An ICU bed is defined as comprising a bed, a patient monitor, a mechanical ventilator, a suction machine and an anaesthesia provider in the vicinity.

ICU beds country wise
Based on that definition, a study titled, National Intensive Care Unit Bed Capacity and ICU patient characteristics in a low income country (Uganda), found that there were 33 ICU beds in the whole country for a population of 33 million people.

The study was conducted by Drs Arthur Kwizera, Jane Nakibuuka anaesthesiologists at Mulago Hospital and Martin Dünser from the Department of Anaesthesiology and general intensive care in Austria.

Valuable equipment
It was also established that sepsis, head injury, acute respiratory distress syndrome are the major causes of mortality in ICU.

Patients in such conditions are many and usually need ventilation. However, the unit has ability to ventilate only six patients at a time. Dr Kwizera in an earlier interview with the Daily Monitor said, “This is because the ICU beds that are fully equipped with the necessary life support machines are only six. Usually, they are all occupied and yet we get requests to take in at least 10 more patients daily. Most of these patients need ventilation.”

Cost of using ICUs
Even with these hiccups, the number of patients seeking admission at Mulago’s general ICU remains high because of its affordable rates. The hospital executive director, Dr Byarugaba Baterana says patients who go to private hospitals initially also end up seeking admission in the hospital’s general ICU because of the cost of being admitted elsewhere.

The assistant commissioner support services at Mulago National Referral Hospital, David Nuwamanya says, “The cost of using the ICU is ideally Shs500,000 a week for general patients all inclusive and private ones pay Shs1.2m per week excluding payment for consultants and drugs.” He adds that a waiver is levied for those patients that can’t pay.”

Dr Kwizera adds, “Treatment is usually free as patients are not admitted basing on their ability to pay but rather who comes first and meets admission criteria. So probably only about 30 per cent of the patients pay because majority can’t pay.”

Therefore, it is monetarily cheaper to be treated from Mulago Hospital compared to private hospital like International Hospital Kampala (IHK) whose Director Ian Clarke says it could cost a patient about Shs1m a day all inclusive.

The difference though is that at Mulago, frequent drug shortages may require a patient to buy the recommended drugs unlike at a private hospital.

That and the fact that many patients have to be turned away because of limited capacity makes the ICU experience frustrating to some people. The good news though is that there are plans to revert this.

As a short term plan, Nuwamanya says, “We are expecting patient monitors four of which will go to the general ICU and are expected to be installed by December this year.” However, this bunch of new patient monitors don’t increase the number of monitors in the ICU as they are expected to replace the worn out monitors being used currently.

Aged equipment
Dr Baterana says, “I admit the machines in ICU are old. We are working on acquiring new ones,” adding that, “ideally, life support machines should work for 100,000 hours if continuously in use which amounts to about 12 years.” And if well serviced and handled they can even last longer. But the life support machines at the general ICU have been in service for much longer. The six fully furnished beds together with other ICU equipment were acquired 16 years ago and are a donation from the government of Japan. Bank of Uganda staff donated two ventilators to the general ICU eight years ago.

Way forward
The assistant commissioner support services says a loan was taken from African Development Bank to help improve the situation at Mulago and the hospital management has prioritised the ICU and its equipment.

In an earlier interview Dr Kwizera recommended that one way forward would be for all regional referral hospitals to be equipped with an eight -12 bed ICU (the minimum standard) and an emergency unit because tragedy can strike from any part of the country. These would then be monitored and supervised from a central unit based at Mulago or elsewhere. He believes that this would go a long way in reducing preventable deaths from road traffic accidents, maternal and childhood illnesses and reduce on the burden of surgical disease.

The current plan is to make the general ICU at Mulago at 40 bed unit. Nuwamanya says, “We are going to procure 40 new monitors, 40 ventilators-the equipment which help the patient breathe, and 30 defibrillators - used for patients who may suffer cardiac arrests,” he said, adding that the loan also provides for expansion of the unit by increasing its bed capacity from the current 12 to 40.”

The assistant commissioner support service says that installation of equipment and expansion of the unit should be completed by May 2013. Ideally, with a 1,500 official bed capacity, 150 of the beds should be high dependency-where critical cases are handled and 50 of them purely for ICU but Mulago Hospital is not close to that figure yet. If the purchases are done, that should increase the number of ICU beds in the country to 73 beds so there will be one bed for every 452,055 Ugandans. Till then, however there will be one bed for every one million Ugandans.

Other ICUs at Mulago Hospital
Mulago has three ICUs each dealing with conditions specific to their departments that need intensive care.

General ICU: This is the only ICU that has ventilators and it is where patients that need help breathing are taken. It provides level II ICU services to all kinds of critically ill patients. Level II care includes mechanical ventilation for longer than 24 hrs, and specific organ support like dialysis and inotropic infusions. This ICU can provide mechanical ventilation, post-operative care, intermittent haemodialysis, peritoneal dialysis, and basic neurocritical care. According to the study by Dr Arthur Kwizera and colleagues, whose mortality rate is 40per cent, which is rather surprising considering the challenges that they face.

Burns ICU: This ensures that all burn and trauma victims receive the specialised care. But if the organs were affected then they are referred to the general ICU.

Paediatric ICU (Acute Care Unit): This is an area within a hospital specialising in the care of critically ill infants, children.

Heart institute ICU: This is a semi-autonomous unit that is self accounting within the hospital that caters for paying patients and open-heart surgery patients. The executive director says it offers help to the general ICU when need arises.

Other High Dependency Units include the labour suite and neurosurgery unit.

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