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Covid: What went wrong with ICU units

A Covid-19 patient in ICU

A Covid-19 patient in ICU

Government and Ugandans may have been lulled into complacency during the one year and three months, from March 2020, when the country had seemingly contained the coronavirus while people stoically endured a partial lockdown.

But the worst of the pandemic is probably here and has caught our healthcare system completely off-guard, unprepared and hugely overwhelmed. There have been more than 71,543 confirmed cases of Covid-19 as at June 18, 2021. The virus has killed at least 660 this far.

And on June 18, President Museveni ordered a second strict 42-day lockdown largely to slow the unprecedented march of the coronavirus.

The country, however, is still short on many things to put up a spirited fight. It is short on cash, medical oxygen, intensive care units and beds, test kits and vaccine doses to deal with the increasingly severe cases of Covid-19.

In over a year, only 1,257,535 Covid-19 tests have been done out of a population of about 42 million and only 821,659 people have been vaccinated. Currently the country’s hospitals combined have 3,100 standard beds, 475 high-dependence unit beds and 218 intensive care unit beds to take care of about 42 million people.

What went wrong? The Semi-Annual Budget Monitoring Report for the financial 2020/2021 released in May, this year, provides some new useful insights into the government strategy, finances and stumbles in its handling of the coronavirus pandemic.

Overall, the report found that the performance of the health sector in response to the Covid-19 pandemic was fair at 61%. Out of the 41,715 Covid-19 cases, the designated public Covid-19 treatment centres attended to only 31% of the cases as at April 29, 2021.

Approximately, 94% of the patients in designated Covid-19 treatment centres (CTCs) were discharged, according to the report. The health sector did not also attain its targets in relation to procurement and distribution of non-medical masks to communities with only 44% of the target reached.

However, overall challenges in the Covid-19 response, according to the report include; inadequate planning partly demonstrated by:

*Lack of pre-planned space for emergency critical care ICU equipment delivered to regional referral hospitals.

Acquirement and remodeling of ICU was scheduled to be done upon delivery of the equipment.

*Lack of training of critical care health workers upon delivery of the emergency equipment.

*The sleeper tents relocated from Namboole to regional referral hospitals, RRHs, were not fully installed and used due to limited space, equipment, and health workers at the RRHs and later drastic reduction of Covid-19 cases.

*Sequencing of projects and interventions partly leading to mischarges, low absorption of both donor and GoU funding. The MoH attributed this anomaly to the emergency nature of the pandemic that required immediate actions.

• Lack of harmonised data and inadequate guidance of CTUs regarding Covid-19 statistics. This led to confusion between Covid-19 confirmed and probable death statistics between MoH, national and RRHs.

• Demotivation of health workers due to delayed payments of risk allowances

Below are the report’s findings word-for-word on the establishment of emergency Intensive Care Units at Covid-19 Treatment Centres.

This involved procurement, distribution and installation of medical equipment at regional referral hospitals as well remodeling ICUs.

The following was established:

The MoH signed two contracts for the supply, installation and commissioning of medical equipment worth Shs 37,517,133,634 in June 2020. The Ministry of Health had cumulatively spent Shs 35,912,056,570 (95%) against the two contracts.

In the first contract the MoH engaged M/S Elsmeed EA Ltd at a contract sum of Shs 26,930,095,500 for delivery, installation and commissioning of ICU equipment in 17 hospitals across Uganda.

The contract was signed on June 18 June 2020 and deliveries were expected by July 20, 2020. This was not achieved partly due to the high global demand for the ICU equipment coupled with the global lockdown at the various manufacturing firms in their home countries.

The delivery date was extended to December 4, 2020, subsequently revised to January 20, 2021, and later to June 30, 2021 in relation to the new Letter of Credit issued on June 24 2020.

As at January 31, 2021, about 1,497 out of 1,553 (96.4%) pieces of equipment were delivered to the respective recipient facilities and 85% of the installations done.

These included: Blood gas analyzers, defibrillators, suction and infusion pumps, nebulisers, mobile x-rays, oxygen concentrators, weighing scales, portable ultrasounds, patient trolleys, ventilators, and ICU beds among others.

By January and February 2021 laboratory equipment such as Blood gas analysers supplied by M/S Elsmeed EA Ltd was not working. Equipment delivered at Soroti and Lacor did not work at all while one delivered to Gulu RRH worked for less than 48 hours.

Health minister Jane Ruth Aceng inspecting Covid testing equipment at Mutukula border

The equipment had issues related to sensors, temperature failures, and frozen screens among others. In an exit meeting held on May 5, 2021, MoH management noted that the equipment was restored in March 2021 and fully operational save for Soroti RRH.

The lack of uninterrupted Power Supply (UPS) equipment affected functionality of blood gas analyzers at various facilities. The second contract was signed between MoH and Joint Medical Stores (JMS) to procure ICU equipment at a sum of Shs 10,587,038,134 on May 24, 2020.

The JMS was expected to deliver 388 pieces of ICU equipment comprised of 28% ventilators, 25% patient monitors, 24% oxygen therapy apparatus, while the rest (22%) were ICU beds.

The equipment was expected to be delivered in six weeks by July 3, 2020, against 100% full payment. This delivery date was not achieved and a change order was issued extending the delivery date to December 15 2020 consistent with the extension of the Advance Payment Bank Guarantee.

This was achieved and by at December 31, 2020, JMS had delivered majority (99%) of the equipment. There were observed variations in the unit cost of the various ICU equipment, for instance the cost of the ICU bed supplied by JMS was Shs 6,799,428 compared to the 6,942,600 by Elsmeed EA Ltd.

This translated into a difference of Shs 143,128 per ICU bed and Shs 8,015,168 for all the beds. However, despite the fact that there were variances in costs, beneficiaries at various Covid-19 Treatment Centres acknowledged that of the ICU equipment supplied by M/S Elsmeed EA Ltd was of higher quality compared to that supplied by JMS.

Beneficiaries were also happy with the intervention and noted that Covid-19 was a blessing in disguise.

“We would never have got this ICUs equipment in 2020.... if it wasn’t for Covid-19 pandemic,” said the director Kiruddu Hospital.

At all facilities visited (January-February 2021), partial installations were done, and almost all the equipment was not optimally utilised. This was attributed to:

i.) Lack of skilled health workers such as anesthesiologists, critical care nurses, intensivists among others to facilitate effective utilisation of the ICU equipment. Some of the cadres required to man this equipment were not part of the approved health staffing structure or norms. Efforts to train critical care nurses were made after the equipment had reached various health facilities.

A number of nurses seconded for the six-month residential training were not enthusiastic about the opportunity due the fact that MoH was not facilitating them. They had to find their own way of survival and this demotivated them. Interactions with the Hospital directors indicated that the MoH would later facilitate the nurses, however this had not been formally communicated to them.

ii) Lack of ready and adequate space to install all the ICU equipment with some facilities not having appropriate infrastructure to install equipment such as ICU pendants due to their weight.

iii) Lack of adequate funds to re-model existing infrastructure.

ICU FACILITIES REMODELED AND EXPANDED

The MoH was engaging regional referral hospitals (RRHs) administrations to provide space to allow for modification of the existing buildings as short to medium term measure to enable installation and use of the emergency ICU equipment that are largely redundant at the RRHs.

At the hospitals where space for remodeling was identified, the MoH transferred funds to enable execution of works. For instance, Shs 1.35bn was transferred to Mbale RRH for the re-modeling of the Surgical Complex in response to Covid-19 Emergency and Shs 450 million to Mbarara RRH for Completion of the Covid-19 Isolation and Treatment Facility as at December 31, 2020.

Additional transfers to Gulu and Masaka were under consideration in the second half of the financial year.

At Mbale RRH it was established that the contract for remodeling of the Surgical Complex had not yet been signed by March 3 2021. The existing contractor therefore continued with the already contracted main works. There was a risk of the hospital utilising these funds to pay for the completed works in the main contract.

The Covid-19 Isolation and Treatment Centre (CITC) at Mbarara RRH was financed by both the government through MoH and Global Health Collaborative (GHC). The MoH contributed Shs 450 million and Shs 100 million from GHC. The facility is expected to accommodate 20 suspects in the isolation unit and 12 confirmed cases in the treatment centre.

M/s Mupa Technical Services was awarded the contract worth Shs 499 million to construct the CITC at the hospital. Works were ongoing as at December 31 2020 and expected to be completed on June 21 2021. The scope of works involved preliminaries, structural works, mechanical, sanitary and electrical installations as well as windows and doors.

External works and water supply among others. The works were supervised by the hospital engineer at a sum of Shs 25 million (1% of the contract sum).

By the time of monitoring done in February 2021, physical progress had commenced to 75%. The structures were in place, doors and windows installed, plastered, roofed, and floor works were ongoing. Pending works included glassing, mechanical and electrical, ceiling works fence, and external works among others. Works were expected to be completed by end of April 2021.

4.3.2.2 Oxygen plants at Entebbe, Kayunga, Mbarara and Mulago National Referral Hospital procured and installed.

The contract for supply, and installation of oxygen equipment for Mulago and Entebbe hospitals was signed on May 5 2020 between MoH and M/s Silver Bucks Pharmacy Ltd at a contract sum of Shs 6,466,382,816 tax exclusive.

The contract provided for a two-year warranty including spare parts and maintenance for three years. They were to supply oxygen plants, 450 cylinders including regulators, humidifier bottles, and cannula among others. Approximately 100% of the sum was paid.

Delivery and installation of four oxygen plants at Mulago Specialised Hospital and one Entebbe and Mbarara RRHs respectively were completed as at December 31 2020. However, the oxygen filling station at Mulago NRH and the oxygen plant at Kayunga RRH hospital had been delivered but not yet installed by March 2021. This was attributed to funding constraints.

OXYGEN EQUIPMENT AT ENTEBBE RRH

The equipment at the three hospitals was in use and well-functioning. The beneficiaries noted a great improvement and stabilisation of oxygen supply. This greatly improved service delivery and timely response to oxygen needs by Covid-19 patients. However, the four plants at Mulago NRH needed urgent maintenance as at April 21 2021.

The hospitals also lacked equipment for harvesting vacuum air important in the suctioning process of patients among other purposes, as well medical air critical in intensive care services.

All hospitals therefore continued to procure medical air from OXY-GAS Ltd among other service providers to enable provision of such services. Health workers had therefore resorted to use of suction machines/pumps to bridge the gap of vacuum air. This was noted to be time consuming.

However, the required equipment for production/harvesting of Medical and Vacuum Air was already delivered under Support to Mulago Hospital Rehabilitation Project, however, it could not be installed and utilised due to delays in completion of works by M/s Roko Construction Ltd.

There is therefore urgent need for the MoH to prioritise expansion and modification of existing oxygen plants to enable harvesting/production of Medical and Vacuum Air within the available resources.

Additionally, the MoH and PPDA should prevail on M/s Roko to pay its subcontractors to enable completion of all pending rehabilitation works at Mulago Specialised Hospital. This will go a long way in enhancing service delivery in critical care departments of beneficiary hospitals.

OXYGEN PLANT HOUSE AT MULAGO HOSPITAL CONSTRUCTED:

On February 22, 2021, the MoH issued a variation of the contract signed with M/s Modul House Engineering and Construction Co Ltd to include construction of an oxygen plant house at Mulago National Referral Hospital.

The variation price was Shs 568,548,330 and the scope of works involved preliminaries, civil works, electrical installations and external works.

The facility was expected to have concrete foundation slab, modular precast reinforced concrete frames, G26 pre-painted iron sheets roof covering on steel trusses, steel/aluminum casement windows and external doors among others.

As at December 31 2020, the main works had been completed and plants installed, however external drainage works had not been completed as at April 21 2021.

Plant residue water had started affecting the walls and general environment of the hospital. Contrary to Public Procurement and Disposal of Public Assets (PPDA) guidelines on proper procurement and contract management, the contractor commenced works on the plant house before signing the contract. This partly led to delayed payments constraining cash flows of the contractor.

© 2016 Observer Media Ltd