On prematurity and renovating a NICU. . .

Every year, we care for almost 1000 neonates in our NICU in Kijabe. . . from our tiniest babies who start around 500 gm to our 5kg babies, but this week was all about our premature ones – or, as Frank calls them – our “tiny giants”.

November 17th is World Prematurity Day, and we had 10 of our babies from this year come back for interviews and some of our current and former moms share their stories – of provision, of their struggle, of their journeys in our NICU as their babies grow day by day.

We are in the middle of our NICU renovation process, and today I spent 3 hours touring our chosen architect around our space, refining their design, figuring how to make the moms’ days easier. . .and our care even better. In the midst of this process – I have had to write a business case to explain why we are expanding our NICU to present to the hospital board.

Even though David lives with me and hears so many of my stories, he learned new things when he read it. . .so in anticipation of opening this new space, I wanted to share a bit of the document here, as a glimpse of my day to day admin life and to learn a little bit more about the amazing work our team does every day for these babies –

((David here. . .to say I learned new things would be an understatement. The neonatal mortality chart is painful for me to look at. If an extreme preterm baby is born elsewhere, they will most likely die. If they are born at Kijabe, they have a good fighting chance. So when I hear about doubling the size of the NICU, it’s not an abstract goal, it’s literally life and death. . .).

BUSINESS CASE FOR THE KIJABE NICU EXPANSION

1.1   Brief Background and Introduction to Neonatal Care in Kijabe

            Kijabe Hospital has provided high level Neonatal Intensive Care Unit (NICU) services for the past 13 years.  In 2008, we started caring specifically for preterm infants that were born in Kijabe Hospital with continuous monitoring, infusion pump fluid administration, and incubator care. In 2010, we began management of  critically ill term infants with meconium aspiration syndrome, and severed sepsis including vasopressor support and ventilation. In 2012, the nursery nurses received upskilling and 6 months of training in NICU and we began using bubble CPAP and administering surfactant to extreme preterm infants.  In 2018, we opened the Kangaroo Mother Care unit, expanding our capacity and enabling standard of care treatment for older premature infants.  

1.2   Needs Analysis (Stewardship)

Demand for our NICU services has remained consistent through multiple healthcare changes including the 2017 strike and 2020 COVID pandemic. In addition, demand for excellent NICU services in conjunction with high risk pregnancy continues to drive referrals to Kijabe Hospital.  In Coverage Nurse calls for referrals, the top 3 requests are for nursery, oncology, and ICU care. We have to either refuse transfers or send patients away because of limited preterm NICU space 10-15 times a month, even during the pandemic and with expansion into an 8 bed unit in BKKH. This is the primary driver in the case for more NICU beds.

1.3   Impact

            Kijabe Hospital NICU provides one of the only options for NICU care outside of major national referral hospitals. In addition, when compared to KEMRI welcome trust data collected in 2018, Kijajbe NICU has the best mortality percentages of any hospital in the country for preterm infants (see Table 2). Expansion of NICU bed space, particularly preterm bed spaces, will increase our capacity for caring for high risk mothers in maternity, reduce our referrals, increase our preterm admissions, and generate revenue through excellent compassionate care fitting this niche need.

            This is in line with our Strategic Plan with goal to lay the groundwork for growth and sustainability while becoming the hospital of choice for specialized medical services in the region.  As we expand our subspecialty care, we keep in mind our values of compassion (care for the most vulnerable), sustainability (consistent patient flow with specialized services),accountability (ability to provide quality eservices to our clients), and employee engagement (training of NICU nurses and specialized care providers).

1.4      Target Beneficiaries (Superior Customer Experience with compassion)

Kijabe Hospital NICU has on average 700-1000 (see above) admissions annually, regardless of political or economic climate, and our goal is to expand by 25% to 1250 admissions/year. Of these admissions, 30% are preterm infants with an average stay of 3 weeks (34-36 week gestational age) to 2 months (<28 week gestational age). Growth of preterm service percentage is shown in Table 3 below and can only be expanded further with expansion of space and equipment.

Expanding nursery will also expand our maternity care, allowing admission and care of mothers with high risk pregnancies whose babies will require NICU care upon delivery.

2.1 Purpose  

Expansion of Bed Space in the NICU by 25% (from 13 beds inside to 20 beds) and expansion of preterm care capability by 25% (pumps, monitors, incubators) with improvement in environmental efficiency (central heat and solar water heating), and acoustics. We will continue with our 8 bed Kangaroo Mother Care as well.

2.2 Objectives

• Increase NICU bed and Preterm care capacity by 25%
• Improve environmental efficiency and cost saving measures through design and function
• Modern design to improve efficiency, care, and patient satisfaction

2.3   Scope

• Remodel and expand 1000 sq foot patient area with central core nursing support, equipment storage, workroom, sluice, isolation, and reception areas
• Electrical, heaters, and duct word to be upgraded
• Medical gas piping to be designed for service to all patient rooms
• All designs to be in line with whole hospital aesthetic in accordance with the master plan
• The iterative design process shall be repeated until the final designs are produced as agreed with the stakeholders. 

2.4 Project Description

1. Increase the cot/incubator space in the main nursery from a current number of 13 to 20 cot/incubator spaces. The 20 cot spaces will include: 
   1. i)  2 separate isolation rooms with capabilities for 2 cot spaces each 
   1. ii)  NICU/HDU space- 8 cot spaces- can be 1 big room or 2 separate ones 
   1. iii)  6 sockets at each cot space 
2. 3 resuscitaire spaces- equipped with oxygen ports/ suction and electricity outlets. 
3. Expressing room with chairs, sinks, counter and a fridge for milk storage 
4. Small store for equipment and supplies (can be pantry size) 
5. Sluice area 
6. Medical gases/ suction– 15 oxygen ports- an increase from current 10. All the cot spaces should have access to the oxygen even if some can be shared.  (10 suction ports, Medical air with blendingcapacity for 5)
7. Reimagined Nurses’ working stations 
8. Sinks at entrance, in main nursery, and in all isolation rooms
9. Overhead heaters or capacity for central heating
10. Shelves/ mounts for all monitors and pumps 
11. Allow for glass partitions for clear sight lines of all patients

2.4 Outcomes

• SUPERIOR CUSTOMER EXPERIENCE: Decreased referrals from maternity and nursery
• OPERATIONAL EXCELLENCE: Improved patient efficiency care and mortality
• STEWARDSHIP:
  •  Increased revenue generation (from current 40,000,000 KES annually to 55,000,000 KES annually by increase in total numbers and percentage of critically ill newborns
  • Improve sustainability through energy efficiency and solar heating

One of our PECCCO students, who had never really cared for a premature baby before coming to Kijabe 9 months ago wrote this about our babies yesterday. I think it shows how much our care goes far beyond medicine and a business plan – it is about hope as we fight with these tiny heroes.

For you created my inmost being;

you knit me together in my mother’s womb.

I praise you because I am fearfully and wonderfully made;
    
your works are wonderful, I know that full well.

My frame was not hidden from you
    
when I was made in the secret place,
    
when I was woven together in the depths of the earth.

Your eyes saw my unformed body;
    
all the days ordained for me were written in your book
    
before one of them came to be.

*on the wall in nursery