EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study

Objective

to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya.

Design

prospective registry-based observational study.

Setting

three HDUs and eight ICUs in Kenya.

Patients

consecutive adult patients admitted between January 2021 and June 2022.

Interventions

none.

Measurements and main results

data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality.

Conclusions

We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients.

Study registration

Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).

Organisation, staffing and resources of critical care units in Kenya

OBJECTIVE

To describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors.

MATERIALS AND METHODS

An online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care.

RESULTS

The survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5-11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9-10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0-81%), and capnography moderate (31% of beds, IQR 0-77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow.

CONCLUSION

This study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers.

Expression of Concern to: A protocol for a cluster-randomized controlled trial testing an empowerment intervention to prevent sexual assault in upper primary school adolescents in the informal settlements of Nairobi, Kenya

An amendment to this paper has been published and can be accessed via the original article.

Empirical Insights for Improving Sexual Assault Prevention: Evidence From Baseline Data for a Cluster-Randomized Trial of IMPower and Sources of Strength

The empirical science of measuring and preventing sexual assault is in its infancy, especially when considering adolescents in developing nations. We analyze pre-intervention data collected in a two-arm cluster-randomized controlled trial of a classroom-based sexual assault prevention program deployed to Class 6 students around Nairobi, Kenya. We estimate that 7.2% of girls were raped in the prior 12 months. We identify school- and individual-level risk factors for rape. We isolate, as much as possible, variation in probability of rape attributable to a subset of these risk factors. We discuss statistical challenges and solutions in each of these domains.

A protocol for a cluster-randomized controlled trial testing an empowerment intervention to prevent sexual assault in upper primary school adolescents in the informal settlements of Nairobi, Kenya

Background

Sexual violence against adolescents is prevalent worldwide and results in significant physical and mental injuries as well as loss of economic and personal potential. Urban informal settlements such as those around Nairobi, Kenya have been shown to have especially high incidences of violence. Research has shown that empowerment interventions for female adolescents can reduce sexual assault. However, these interventions have had limited testing in urban informal settlements, with young adolescents, or in coordination with complementary programs for male adolescents.

Methods/design

This study was a two-arm, parallel, cluster-randomized trial testing a combination of a previously-tested girls’ intervention, IMPower, and a newly revised boys’ intervention, Source of Strength. Clusters were defined as schools within the informal settlements; participants were adolescent girls and boys in class 6, generally between the ages of 10–14 at baseline. Data collection began in January 2016 and continued through December 2018. The primary outcome was the change in incidence of self-reported sexual assault among girls from baseline, compared to a life skills standard of care intervention. Secondary outcomes included experiences of physical and emotional violence, as well as determining the effects of the intervention on self-efficacy, self-esteem, and gender attitudes and beliefs, and how those effects led to changes in experience of sexual assault. For the primary outcome and several of the secondary outcomes, we used an intention to treat estimand.

Discussion

This was the first randomized controlled trial with longitudinal follow-up of an empowerment self-defense approach to violence prevention for adolescents in informal settlements. The large size and rigorous design supported analysis to understand multiple subgroup experiences in the hypothesized reduction in sexual assault. The study was also unique in its focus on young (10–14 years of age) adolescents and in engaging both boys and girls in separate but coordinated curriculums. The focus on a highly vulnerable and understudied population will make it a significant contribution to the literature on violence prevention.

Trial registration

Clinical Trials.gov #NCT02771132. Version 3.1 registered May 2017, first participant enrolled January 2017. Retrospectively registered.

Prevalence and risk factors for sexual assault among class 6 female students in unplanned settlements of Nairobi, Kenya: Baseline analysis from the IMPower & Sources of Strength cluster randomized controlled trial

BACKGROUND

Gender-based violence (GBV) is a crucial global health problem among all age groups, including adolescents. This study describes incidences of GBV, as well as factors associated with sexual assault, among female adolescents in class six living in urban informal settlements in Nairobi, Kenya.

METHODS

Study participants were interviewed using a structured survey instrument focusing on experiences of GBV, including emotional, physical, and sexual violence, and corresponding perpetrators, as well as gender attitudes, alcohol use, self-efficacy, and previous sexual experiences. Summary statistics and clustered bootstrap confidence intervals were calculated for social behaviors and violence rates. Stepwise logistic regression identified variables associated with an adolescent's experience of sexual assault.

FINDINGS

In this population 7·2% of adolescent girls reported being raped in the prior twelve months, with 11·1% of these rape victims reporting over five experiences. Among the 21·3% who report having had a boyfriend, 38·1% reported emotional, physical, and/or sexual intimate partner violence (IPV). Boyfriends were identified most often as perpetrators, accounting for 46·3% of reported lifetime rapes. Previous experience of physical (p = <0·001) or emotional (p<0·001) IPV and home violence (p<0·001) were risk factors for being raped, while high self-efficacy (p<0·001) was a protective factor.

INTERPRETATION

Sexual assault and GBV are major challenges in this highly-disadvantaged population. Novel prevention efforts are needed for this age group, as prevention is often targeted at older adolescents. Prevention efforts should focus on assaults by perpetrators known to adolescents, especially boyfriends, and may need to account for the adolescents' previous experience of, and exposure to, violence.

Successful pregnancy outcome following laparoscopic myomectomy: case report

Laparoscopic myomectomy is now widely used as an alternative to laparotomy in the management of symptomatic uterine fibroids. The advantages of this minimal access approach outweigh those of the open techniques. The pregnancy outcomes between the two methods have been studied and are comparable, but there still exists a lot of scepticism locally concerning this. It is against this background that we present a 31 year old nulliparous lady who had a two year history of primary infertility secondary to multiple uterine fibroids, the largest being fundal and measuring 6.6cm. She underwent a successful laparoscopic myomectomy in November, 2006 and conceived spontaneously in February 2007. Her antenatal follow up was uneventful. She delivered a live male, 2,650 grams by Caesarean section in October, 2007 and had an unremarkable peuperium. With the availability of proper equipment, instruments, and adequately developing skills, laparoscopic myomectomy is feasible locally and with proper patient selection could result in favourable outcome as it is elsewhere.

Total laparoscopic hysterectomy at the Aga Khan University Hospital, Nairobi

OBJECTIVE

To determine the outcomes of total laparoscopic hysterectomy at the Aga Khan University Hospital, Nairobi. To create awareness on the availability of the procedure and to recommend the procedure as a suitable option to total abdominal hysterectomy.

DESIGN

A retrospective case analysis.

SETTING

Private practice in a private hospital set up.

SUBJECTS

One hundred and twelve laparoscopic hysterectomies were performed at the Aga Khan University Hospital, Nairobi. These cases have been reviewed, analysed and presented between May, 2000 and May, 2007.

INTERVENTIONS

Total laparoscopic hysterectomies done.

EXCLUSIONS

All cases performed at other hospitals in Nairobi and Mombasa, and all cases where the author was not the principal surgeon.

RESULTS

The ages ranged from 36 to 74 years, the mean age being 48 years. The patients parity ranged from 0 to 9. Fifty seven point one percent of the patients presented with heavy prolonged periods with clots. Of all the cases performed 54.4% gave a history of a previous laparotomy or Caesarian section. The uterine size by clinical assessment ranged from bulky to 28 weeks. The operating times ranged from 25 to 240 minutes, scope in to scope out. The average hospital stay for patients undergoing total laparoscopic hysterectomies was 2.1 days. There were no intraoperative complications encountered. The majority of the uteri weighed between 101-300 g (50.8%).

CONCLUSIONS

Laparoscopic surgery is now well accepted by specialists and patients. Where facilities allow advocating total laparoscopic hysterectomy for benign uterine pathology can be considered as a suitable option to abdominal hysterectomy.

Laparoscopic assisted vaginal hysterectomy for benign uterine pathology: is it time to change?

OBJECTIVE

To determine the acceptability and outcome of laparoscopic assisted vaginal hysterectomy at the Aga Khan Hospital, Nairobi.

DESIGN

A retrospective case analysis.

SUBJECTS

Two hundrend and twenty nine cases of laparoscopic assisted hysterectomy were undertaken at various hospitals in the presence of the principal author from May 2000 to December 2003. Of these 149 (65.06%) were performed at the Aga Khan Hospital, Nairobi. These cases have been reviewed, analysed and presented.

EXCLUSIONS

All cases performed at the various other hospitals were excluded, along with those cases of laparoscopic assisted vaginal hysterectomy which are now being performed by other consultants obstetricians and gynaecologists, on their own and who have now learnt the technique

RESULTS

Over the last three years, 149 cases of laparoscopic assisted vaginal hysterectomy were undertaken at the Aga Khan Hospital, Nairobi. Annual case load increased from three cases in 2000, to 71 cases by December, 2003. Fifty one percent of the patients were between 46 to 50 years of age, while 93.9% were para 2 + 0 and above. Menorrhagia was the presenting complaint in 55.7%. The operative procedure was performed in 91 to 120 minutes in 58.3% of the cases. Hospital stays were two nights in 95.3%. The complications encountered were bladder injury (3.4%), bowel injury (1.3%), port site herniation (0.67%) and a delayed recognition of bladder injury (0.67%).

CONCLUSION

In Kenya, laparoscopic surgery is gradually being accepted by gynaecologists and general surgeons. The conversion from total abdominal hysterectomy to laparoscopic assisted vaginal hysterectomy for benign uterine pathology is now becoming more popular amongst gynaecologists and patients. With time laparoscopic assistance during hysterectomy will become the norm.

Experience with laparoscopic surgery at the Aga Khan Hospital, Nairobi

OBJECTIVE

To outline the experience of laparoscopic surgery at the Aga Khan Hospital, Nairobi, and to determine the acceptability and outcome of the various procedures undertaken laparoscopically.

DESIGN

A retrospective case analysis.

SUBJECTS

Four hundred and seventy eight cases of laparoscopic surgery were undertaken in Nairobi from May 2000 to May 2002 in the presence of the principal author, of these 408 cases (85.35%) were performed at the Aga Khan Hospital in Nairobi. A review of these cases and their outcomes are analysed and presented.

EXCLUSIONS

Loss of client records, or follow up, all diagnostic procedures and all procedures performed at the three other private hospitals, namely; Nairobi Hospital, Nairobi Womens' Hospital and the M.P. Shah Hospital, have been excluded in this review.

RESULTS

Minimal access surgery will in time find its place amongst the institutions in Kenya. In the last two years 408 cases were undertaken at the Aga Khan Hospital, Nairobi, involving a pool of 48 consultants obstetricians and gynaecologists and general surgeons. The case load increased from 7.0 cases per month in 2000 to 22 cases per month in 2001. Sixty four point four six percent of the patients spent one night in hospital, while 1.96% had conversion to laparotomy intraoperatively. Thirty nine point seven percent of the patients had no previous surgery. The surgical procedures performed included laparoscopic adhesiolysis (34.55%) and tuboplasty (17.89%) for primary or secondary infertility, 33 cases (8.08% ) for the management of ectopic pregnancies, laparoscopic myomectomy (15.44%), ovarian cystectomy (16.91%), ovarian drilling (4.65%), laparoscopic assisted vaginal hysterectomy (15.19%) and total laparoscopic hysterectomy (2.20%). All cases were reviewed by the consultant pool one week after discharge. The major complications encountered included bladder injury (0.49%) and gut injury (0.73%).

CONCLUSIONS

Minimal access surgery in gynaecology and general surgery is gaining remarkable ground worldwide and has tremendous potential in Kenya. It is evident that in trained hands, the common gynaecological operations and certain general Surgical procedures can be undertaken safely, laparoscopically. Minimal access surgery is acceptable to the patients and significantly favourable outcomes have been established in all the cases undertaken, thus far. Patient compliance has been excellent in this series.