MAKER MOVEMENT FOR MATERNAL
NEWBORN AND CHILD HEALTH Needs Assessment Results from KNH
Natasha Kanagat & Emily Stammer
JSI Research & Training Institute, Inc.
March 2014
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Introduction
Innovations aims to and creative interventions and strategies that can address barriers to improving coverage of basic MNCH services.
Maker Movement for Maternal, Newborn
and Child Health (“Maker”)
Innovations for
Maternal, Newborn
& Child Health
(“Innovations”)
initiative.
www.innovationsformnch.org
Introduction
The Maker Movement for MNCH aims to address gaps in the supply and availability of functioning MNCH medical equipment at Kenyatta National Hospital (KNH) and select health
facilities that refer women to KNH for labor and delivery
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Objectives of Needs Assessment
Describe procurement and
maintenance processes
Assess magnitude and causes of
shortage
Assess availability and functionality of
equipment
Document trends in maternal and
neonatal mortality
Develop shortlist of equipment
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Methods: Data Collection
Key Informant Interviews
Document Reviews
Patient Tracing
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Methods - Key Informants
• Nurse on duty, Scrub nurse, Deputy midwife, Chief midwife, Resident
Labor and Delivery
• Nurse on duty, Resident, Head of Neonatology, Chief Nurse, Deputy Nurse
Newborn Unit
• Medical Engineering Technologist, Head of Biomedical team Biomedical
• Supplies Officer, Head of Procurement, Accounts Clerk (Finance), Supply Management Officer Procurement
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Methods: Data Collection Team
Procurement Consultants Supply Chain and Procurement, Labor and Delivery Ward & Theatre, Newborn Unit and NICU, Biomedical Unit, Finance, Accounting, Legal, Resource Mobilization
OB/GYN Consultant Labor and Delivery Ward & Theatre
Neonatology Consultant Newborn Unit and NICU
JSI team Biomedical Unit, Hospital statistics
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Methods
Key Informant Interviewer Selection
Convenience sampling
Expertise and experience at KNH
Quality Assurance Mechanisms
Daily debriefs
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Methods
Data Management
Stored on secure network
No identifying information
Limitations
Some respondents not comfortable signing full name on consent
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Results – Labor and Delivery*
56%
44%
Delivery Type
Vaginal
Caesarean
Section
12,860 deliveries
97% live births
120 maternal deaths
*2013 data from hospital records
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Infrastructure and General Layout
Capacity
-------------------------------------------------------------------------
30 deliveries a day | Intended
Sometimes 60 deliveries a day | Actual
------------------------------------------------------------------------
Operating Theatre Capacity
2 Operating Theatres
Patients in line to deliver
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Results: Main causes of maternal mortality *
Sepsis from complicated abortions and obstructed labor, cardiac failure,
malaria, complications of HIV, embolism, poor general anesthesia reversal,
and renal failure.
*2013 data from hospital records
Post-partum
hemorrhage
Eclampsia
18 41
120 maternal deaths
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Results – Labor and Delivery
Consumables
All consumables except hand soap, available and functional
Equipment Categories
Available
Functional
In use
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Results – Labor and Delivery
Equipment
Available, functional and in use
Includes: Many pieces of equipment
Oxygen flow meters
Infusion sets
Central Sterilizer
Sphygmomanometer
Fetal Stethoscope
Delivery beds
Defibrillator
Cord clamping set
Suturing set
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Results – Labor and Delivery
Equipment
Available, functional
and not in use
Point of use ultrasound
Available, with limited
function and in use
CTG Machines
Patient beds
Lack of training
Reason/s not in use or not fully
functional
Lacks paper for printing
Difficult to maneuver
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Results – Labor and Delivery
Equipment
Available and non-
functional
Portable and mounted
examination lights
Vacuum extractor
Sphygmomanometer
Operating table
Vital signs monitor
Electric fault
Reason/s not fully functional
Suspected electrical fault, lacking
suction cup
Mercury leak
Not maneuverable
Screen broken
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Results – Labor and Delivery
Equipment
Unavailable but essential equipment
Refrigerator Thermometers
Wall Thermometers
Infusion pumps/dosimeters
Critical care equipment (e.g. vital signs monitors and resuscitation equipment)
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Results – Labor and delivery
Equipment
Available but inadequate in number
Equipment # Have Additional #
Needed
Patient bed 30 10
Delivery bed 3 2
Drip stands 15 30
Operating table 1 1
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Table 1: Most problematic equipment in labor ward floor
*Equipment that breaks most Parts that break Reasons why they break
1.Blood pressure machine
-mercury overflowing
-Electrical fault for automatic ones
-Use by untrained personnel
-Over use due to the large number of patient
-They are few hence get moved from room to room causing
damage
2.Suction machine -Lack of vacuum pressure
-Electrical fault
-Poor quality of suction machines procured
3.Delivery couches/beds -Inability to manipulate the bed i.e. faulty
hydraulic system
-Torn mattresses
-Wheels cannot move
-Poor quality
-Staff not all trained on use
-Old
4.Drip stands -The hangers break
-The knobs break
-The stand break then becomes imbalanced
-Poor quality
5.CTG machine -Electrical faul -Not known
6.Examining light -Bulb gets burnt often
-The electric plugs are stole
-The screws holding the glass get loose
-Cheap bulbs
-Poor maintenance
-Poor quality
7.Doppler fetoscope -Batteries get low -Takes long to replace batteries
8.Spot light -Batteries get low
-Electric fault
-Poor quality
-Takes long to replace batteries
9. Resuscitator -Oxygen flow cannot be regulated
-Heat cannot be controlled
-Old
10. thermometer -For automatic batteries get low
-Breaking
-Takes long to replace batteries
-They are fragile
*Not in any order
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Table 2: Most problematic equipment in Labor ward theatre *Equipment that breaks most Parts that break Reasons why they break
1.Vital signs Monitors
- Blood pressure monitoring part
-Oxygen saturation part
-Electric fault
-Gives wrong readings
-Electric cord connection break
-Dropping of equipment
-Improper handling
-Poor maintenance
2.Operating tables -Inability to manipulate the table i.e. faulty hydraulic
system -Poor maintenance
-Old
-Over use due to patient load
-Lack of maintenance
3.Diathermy -Diathermy lead
-Diathermy patient plate
-Foot pedal (switch)
-Electric fault
-Over use due to patient load
-Poor maintenance
-Careless handling by all staff
4.Suction Machine -Part that creates vacuum
-Lack of suction tubes
-Broken collecting bottles
-Electric fault
-Poor maintenance
-Poor handling
-Over use due to patient load
5.Macerator -The spinning plate for crushing
-Electric fault
-Careless handling
-Poor maintenance
-Overuse due to patient load
6.Anaesthetic machine -Ventilator
-Electric fault
-Oxygen tubes
-Container that carries sodalime
-Knobs
-Blood pressure cuff
-Over use due to patient load
-Careless handling
-Poor maintenance
7.Instruments e.g. sponge holding forceps,
artery forceps
-The joints break
-They get blunt
-Long soaking in jik
-Rusting
-Old
8. Trolleys
-The wheels come out
-The surface comes off
-Lack of lubrication
-Jik pours on it when washing floors
-Rusting
*Not in any order
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Users and Staff Training on Use of Equipment
Users
Doctors
Nurses
Training Received
Largely on-the-job training
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Results – Newborn Unit
2013 Statistics
1,115 neonatal deaths
~73/month admitted - LBW
Capacity
Intended for 50 neonates
Operates at double capacity (sometimes triple)
NICU – 4 bed capacity but often have 5-6 beds
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Results: Main causes of neonatal mortality
(Feb 2014 snap shot)
Sepsis, respiratory distress syndrome , neonatal jaundice, congenital malformations,
post op complications, complicated surgical cases.
Asphyxia
Prematurity complications
32 24
215 admissions (Feb 2014)
88 neonatal deaths
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Results – Newborn Unit
Consumables
All consumables except hand sanitizer, available and functional
Equipment Categories
Available
Functional
In use
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Results – Newborn Unit
Equipment
Available, functional and in use
Includes: Select equipment, but not in adequate number
Refrigerator with thermometer
Infant radiant warmer
Flow meters
Neonatal thermometers
Central sterilizer
Fetal stethoscope
Infusion sets
Drip stands
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Results – Newborn Unit
Equipment
Available, functional
and not in use
One CPAP Machine
Available, with limited
function and in use
Incubators
Ventilators
Baby Cots
Radiant Warmers
Demonstration
Unit
Reason/s not in use or not fully
functional
Broken humidifying component
Broken doors and sleeves
Not maneuverable
Broken heating component, light
not always functional, suction
not working
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Results – Newborn Unit
Equipment
Unavailable but essential equipment
Wall thermometer
Bilrubinometer
Haemogas analyzer (part of mini lab)
Transport incubators
Minilab equipment
Echocardiography machine with neonatal probes for ultra sonography
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Results – Newborn Unit
Equipment
Available but inadequate
in number
Equipment # Have Additional #
Needed
Incubator 15 7
Ventilator 6 4
Radiant
heater/resuscitation
tables
7 6
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Users and Staff Training on Equipment – NBU
Users
Clinicians
Nurses
Training Received
Formal
On the job
Remains a challenge
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Most Problematic Equipment | Breakdown
Incubator
Ventilator
machine
Photo
therapy
lamp
Fluid pump
Radiant
warmer
Suction
machine
Over use
Poor handling
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Results – Biomedical Unit
31 staff: engineers, technologists & technicians
8 Workshops across user areas
Types of maintenance
Planned preventive maintenance
Corrective maintenance
Breakdown maintenance
Maintenance Requests
Phone
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Biomedical Unit: Staff Training
Formal Training
Stipulated by Contract
Informal Training
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Biomedical Unit: Budget
Daily operations
Maintenance
Procurement
(spares)
What is included
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Biomedical Unit: Budget
Timing
Annual
History of purchases and
forecasted equipment
needs
Other departments
contribute funds for repairs
and procurement
(depends on the piece of
equipment)
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Role in Procurement: Biomedical Unit
Developing Specifications
Work with the users (medical and nursing staff) to develop
specifications when ordering new pieces of equipment
Challenges with developing user specs
Iterative process
Challenge to involve stakeholders during each iteration
User ownership of specs document
New developments
Multi-disciplinary committee established
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Biomedical Unit: Equipment most difficult to fix /calibrate
Equipment Parts of the
equipment that
break down
Reasons for
breakdown
Reason for delay in
repair/calibration/maintenance
Infant Incubator Oxygen sensor
Power board
Overuse
Power surges
Age of equipment
Lack of spare parts locally
Infant Ventilator Oxygen sensor
Flow sensor
Overuse Lack of spare parts locally
Patient monitors Multi Measurement
Server module
Overuse Lack of spare parts locally
Suction Machines
TBD
Vacuum extractor
Weighing Scale
Nebulizer
Phototherapy Unit* Lack of calibration equipment
Obstetric ultrasound Power supply board
Probe
Power surges
Probe is expensive
Lack of spare parts locally and lack of
knowledge/skills within the biomedical
team
Resuscitation table Heating element
Oxygen control knobs
Over use
Mishandling by users
Lack of technical knowledge/skills within
the clinical team
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Results - Procurement
Background
Public Procurement and Disposal Act, 2005
Increase transparency and accountability of use of
public funds used to purchase medical equipment and
consumables at KNH, as well as define a process for
open and competitive procurement.
For KNH, emphasizes general equipment
specifications instead of outlining specific
brands/models
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Results - Procurement
Procurement of Spare Parts
Inventory management done by the biomedical unit for all
clinical units/departments
Financial constraints limit the biomedical unit from
stocking adequate supply of parts for all equipment; the
unit is reliant on the reliability of suppliers to provide the
replacement parts in a timely manner.
Equipment is not standardized spare parts are not
standardized either. This lack of standardization
undermines the efficient use of financial resources for
ensuring a reliable supply and availability of functional
equipment.
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Limitations
No data on behavioral interventions within KNH
Respondent Bias
Appropriate population statistics not available
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How will results be used?
Results of KNH Needs Assessment will be combined
with results from Health Facility Assessment
2 day workshop on March 26-27 to decide on critical
pieces of equipment that Maker will build
Your feedback and comments are critical to the
success of this workshop
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Thank you KNH for your cooperation and
enthusiastic participation. This study would not have
been possible without you.
Thank you
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