U.S. Nurse Volunteers Help Open the First PICU in Nigeria
Image: Courtesy of Rachel Baskin
In 2019, a team of medical professionals from the East Coast traveled to Nigeria to open the country’s first Pediatric Intensive Care Unit (PICU). As part of the Nigeria Pediatric ICU (PICU) Project for the Health Place for Children Initiative, Erin Dwyer, MSN, APRN, ACCNS-P, CCRN-K, Rachel Baskin MSN, RN, CPN, Hilary Daugherty, RN, as well as several other nurses traveled abroad. Since its inception, a team has presented Zoom education in 2021 and went in person in 2022 to provide ongoing education.
Dwyer is currently at Clinical Nurse Specialist in the Pediatric ICU (PICU) at Nemours Children’s Hospital as well as pursuing her DNP at Villanova University with anticipated graduation of Fall 2023. Daughtery has been working in the PICU at Nemours Children’s Hospital for the last 11 years after starting as a new grad in the internship program. Baskin, on the other hand, is currently working as a per diem ICU Float RN at Nemours Children’s Health and a Nursing Professional Development Specialist at Children’s Hospital of Philadelphia. She is also pursuing her Ph.D. at Villanova University.
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The brainchild of Odiraa Nwankwor, MD, MPH, a pediatric intensivist from Nigeria who practices at Nemours Children’s Hospital in Wilmington, Delaware, and Cooper University Hospital in Camden, New Jersey this PICU was desperately needed in Nigeria.
Image: Dr. Odiraa Nwankwor
According to the World Health Organization’s (WHO) latest data, from 2017, 77% of healthcare costs are out of pocket for Nigerians. Most Nigerians do not have health insurance of any kind and the poorest Nigerians have extremely limited access to quality health care. In 2018, the Nigeria Center for Disease Control (NCDC) had a government budget that was less than $4 million, which is less than 0.02 cents per Nigerian per year for healthcare. Furthermore, Nigeria has just 2.27 doctors working in the country for every 10,000 people.
“Nigeria is a low resource area, so one obvious challenge is resources. The Nigerian medical personnel we were working with were incredibly intelligent, but they don’t have access to equipment and supplies that are easily accessible here in the States, which limits how much they are able to do in many circumstances. Another huge challenge is that there is no kind of medical insurance, you “pay as you go” when being cared for,” said Hilary Daugherty, RN. “ For instance, if the medical team would like to send a lab or get an X-ray or give a medication they first have to go to the family and see if they are able to pay for it before they can move forward. This means the team really has to weigh each decision they are making to care for their patients, because they don’t want to have the family pay for things that are unnecessary.”
Nigeria is ranked one of the poorest countries in the world. Over 50% of the population or 86.9 million people live in poverty. According to UNICEF, almost half the 180 million population are currently under the age of 15. Nearly 31 million are under the age of 5 while each year at least 7 million babies are born. Furthermore, each year approximately 262,000 babies die at birth, the world’s second-highest total. Infant mortality currently stands at 69 per 1,000 live births while for under-fives it rises to 128 per 1,000 live births. More than half of the under-five deaths result from malaria, pneumonia, or diarrhea. These are ALL preventable illnesses. With the introduction of a PICU, these children will have an increased chance at survival.
“In my home country, pediatric medical services – particularly intensive care services — are often substandard, and it’s a sad fact that one out of every eight children born in Nigeria will die before age 5 often of preventable diseases,” said Dr. Nwankwor. “We established this mission to help the citizens by building and maintaining strong health systems through international collaboration and support.”
Image: Courtesy of Rachel Baskin
Nwankwor took into consideration a multitude of factors and ultimately selected the University of Nigeria Teaching Hospital (UNTH) in Ituku-Ozalla, Enugu as a pilot site for the first organized PICU in his country. According to their website, in September 2019, a 10-member team made up of 4 doctors (3 pediatric intensivists and 1 pediatric surgeon), 4 pediatric ICU nurses, and 2 respiratory therapists traveled to UNTH Enugu to establish a 5-bed PICU and started the initial phase of training for the local doctors, nurses, and physiotherapists (who function as respiratory therapists).
Nurse.Org was able to speak with several of the nurses involved in the project to discuss the initial project, ongoing education, and the impact the PICU has had and will continue to have on the pediatric population in Nigeria.
Nurse.Org (NO): What was the experience like helping set up the PICU?
Erin Dwyer MSN, APRN, ACCNS-P, CCRN-K (ED): It was such a humbling experience. We learned as much as we taught. The people of Nigeria were so gracious and thankful for our time, and were extremely welcoming to us. We tried to observe the care they provided, rather than jumping right in and taking over, so we developed a really nice collaborative relationship with them. They trusted us to guide them, and allowed us to care for patients alongside them. It was really life-changing!
NO: Why do you feel it was important to help start a PICU in Nigeria?
Rachel Baskin MSN, RN, CPN (RB): I believe that all children should have access to critical care medicine and advanced medical care, no matter where they live. I hope that we have created a sustainable program of pediatric critical care that can be replicated across other low- and middle-resource countries.
ED: Despite many interventions to prevent childhood illness in Nigeria, children are still becoming critically ill without access to appropriate care. Sharing our knowledge of caring for critically ill children is key to helping provide additional care options for the children in Nigeria, and across the continent of Africa.
Image: Courtesy of Hilary Daugherty
NO: What are some of the major challenges that you faced during the project?
ED: Understanding the scope of practice for nurses in another country was challenging. We tried to cater our education to the needs of the nursing team and had to make many adjustments in the moment as we learned more about the scope and experience of the team. Also, much of our teaching was developed based on our systems in the United States. Teaching to nurses in a low-resource area was challenging, as they do not have access to all of the technology and diagnostic tests that we do. We had to creatively work with the nurses to understand what technology they had access to, in order to make sure that we were not teaching them to perform a skill in a way that wasn’t realistic for them.
RB: In the United States, we are used to having everything we need right at our fingertips. If I need a supply or a piece of equipment, I can go to the supply room and get it, or I can call someone and have it delivered to the unit. When we were assisting in patient care in the Nigerian PICU, we had to be cognizant of what supplies we had and what was different from what we were used to. For example, we wanted to get a chest X-Ray on a trached patient after changing vent settings. The X-Ray machine was rolled into the PICU by 5 people because it had to go up a small step into the unit. By the time it was at the patient’s bedside, the battery had died and needed to charge. We couldn’t get the X-Ray because the machine wouldn’t turn on-- even after it had been charging. While it was challenging to adapt to our surroundings, we learned so much from the healthcare professionals in the PICU. The medical teams we worked with in Nigeria are so smart and passionate about providing the absolute best care for their patients.
NO: When traveling back to Nigeria this past year, what education did you provide to the nurses/staff?
RB: We had the opportunity to educate the PICU staff at the bedside at University of Nigeria Teaching Hospital (UNTH), as well as providing lectures and hands-on skills stations in the afternoon to healthcare providers from across the country. The PICU staff were caring for a patient with a tracheostomy that had not changed since his cannulation a few months prior. We had an infant manikin with us that had a tracheostomy in it, so we were able to train the staff at the bedside in performing trach changes safely, and then observed and coached the staff into doing the trach change on the patient. During rounds, I noticed that the doctors wanted to place a foley catheter in a female infant. The doctor was having a hard time seeing the urethra, so I asked if I could assist her by holding the patient’s legs in a “frog-leg” position to increase the visibility of the urethra. It was so special to provide in-the-moment teaching to healthcare providers who are so willing to learn. With my assistance in holding the patient, the doctor was able to insert the catheter.
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Hilary Daugherty, RN (HD): Our team provided education to a group of 50+ medical professionals Monday- Friday for 2 weeks. There were 20 nurses who came for the training. They were all very eager and willing to learn. Early on we realized that the nurses in Nigeria, where we were working, do not have the same responsibilities that we have in the States. They do not start IVs, they do not place tubes (foley, NG, ND), they do not give IV meds, they do not complete or record frequent assessments. They are able to give enteral meds and feeds and bathe their patients, but that was about it.
Image: Courtesy of Hilary Daugherty
Image: Courtesy of Hilary Daugherty
NO: What are the next steps for the PICU in Nigeria?
HD: The plan is for us to send in a team yearly. They currently are sending their doctors and nurses to Kenya and South Africa for critical care internships/fellowships. As their team gets more intensive training and experience we plan to go in and work alongside of them more on a shift to shift basis, and supplement education as necessary. Ideally, we would love for a hospital here in the States to adopt the Nigerian PICU so that they could come here from time to time as well as continue to send groups to them.
RB: We have recently discussed the potential to provide online education to the healthcare providers in Nigeria in the meantime until another group can fly over.
Image: Courtesy of Hilary Daugherty
