Implementation of a pediatric trauma registry at a national referral center in Kenya: Utility and concern for sustainability.

BACKGROUND: Pediatric trauma disproportionately affects low- and middle-income countries, particularly the pediatric trauma systems, are frequently limited. This study assessed the patterns of pediatric traumatic injuries and treatment at the only free-standing public children's hospital in East Africa as well as the implementation and sustainability of the trauma registry. METHODS: A prospective pediatric trauma registry was established at Shoe4Africa Children's Hospital (S4A) in Eldoret, Kenya. All trauma patients over a six-month period were enrolled. Descriptive analyses were completed via SAS 9.4 to uncover patterns of demographics, trauma mechanisms and injuries, as well as outcomes. Implementation was assessed using the RE-AIM framework. RESULTS: The 425 patients had a median age of 5.14 years (IQR 2.4, 8.7). Average time to care was 267.5 min (IQR 134.0, 625.0). The most common pediatric trauma mechanisms were falls (32.7 %) and burns (17.7 %), but when stratified by age group, toddlers had a higher risk of sustaining injuries from burns and poisonings. Over half (56.2 %) required an operation during the hospitalization. Overall, implementation of the registry was limited by the clinical burden and inadequate personnel. Sustainability of the registry was limited by finances. CONCLUSIONS: This is the first study to describe the trauma epidemiology from a Kenyan public pediatric hospital. Maintenance of the trauma registry failed due to cost. Streamlining global surgery efforts through implementation science may allow easier development of trauma registries to then identify modifiable risk factors to prevent trauma and long-term outcomes to understand associated disability.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients.

INTRODUCTION: Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States. METHODS: We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap. RESULTS: We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different. CONCLUSIONS: Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Breast Health Awareness: Understanding Health-Seeking Behavior in Western Kenya.

INTRODUCTION: In Kenya, patients with breast cancer predominantly present with late-stage disease and experience poor outcomes. To promote early-stage diagnosis, we implemented the Academic Model Providing Access to Healthcare (AMPATH) Breast and Cervical Cancer Control Program (ABCCCP) in Western Kenya. OBJECTIVE: The aim of this study was to assess differences between patients presenting to health facilities and health fairs. METHODS: This was an institutional Review and Ethics Commitee-approved retrospective cohort study of all individuals who underwent clinical breast examination (CBE) via local healthcare workers in Western Kenya. From 2017 to 2021, the program hosted health fairs, and trained healthcare providers at health facilities to complete CBEs. Results were analyzed using the Chi-square and Kruskal-Wallis tests, with an α < 0.05. RESULTS: Over a 5-year period, the ABCCCP completed 61,812 CBEs with 75.9% (n = 46,902) performed at a health facility. Patients presenting to health fairs were older (44 vs. 38 years; p < 0.0001) and had higher risk factor rates including early menarche, family history of breast and ovarian cancer, and use of alcohol or smoking. Only 27.6% of patients with an abnormal CBE underwent core needle biopsy, and only 5.2% underwent repeat CBE over the 5-year period, of whom 90.3% presented to health facilities. CONCLUSIONS: Successful uptake of CBE through the ABCCCP is the first step to introduce breast health awareness (BHA). Benefits of broad advertisements for health fairs in promoting BHA may be limited to a single event. Poor rates of repeat examinations and diagnostic testing of abnormal CBEs indicate additional resources should be allocated to educating patients, including about possible treatment trajectories for breast cancer.

Bilateral trauma case conferences: an approach to global surgery equity through a virtual education exchange.

Purpose: With increased interest in international surgical experiences, many residency programs have integrated global surgery into their training curricula. For surgical trainees in low- and middle-income countries (LMICs), physical exchange can be costly, and laws in high-income countries (HICs) prevent LMIC trainees from practicing surgery while on visiting rotations. To enrich the educational experience of trainees in both settings, we established a monthly virtual trauma conference between surgery training programs. Methods: General surgery teams from two public institutions, a public university with two surgical training programs in Kenya and a public university with two level I trauma centers in the United States, meet monthly to discuss complex and interesting trauma patients. A trainee from each institution presents a clinical case vignette and supplements the case with pertinent peer-reviewed literature. The attendees then answer a series of multiple-choice questions like those found on surgery board exams. Results: Monthly case conferences began in September 2017 with an average of 24 trainees and consultant surgeons. Case discussions serve to stimulate dialogue on patient presentation and management, highlighting cost-conscious, high-quality care and the need to adapt practice patterns to meet resource constraints and provide culturally appropriate care. Conclusion: Our 5-year experience with this virtual case conference has created a unique and robust surgical education experience for trainees and surgeons who have withstood the effects of the pandemic. These case conferences have not only strengthened the camaraderie between our departments, but also promoted equity in global surgery education and prioritized the learning of trainees from both settings.

AMPATH surgical app: Low-cost simulator for the open appendectomy.

BACKGROUND: Due to a shortage and maldistribution of surgeons within Kenya, doctors with limited formal surgical training often perform emergency surgical procedures such as appendectomy. This lack of training can compromise patient outcomes and complicate care delivery. Our aim was to develop a low-cost simulator and skills curriculum to effectively teach open appendectomy. METHODS: Surgeons from 4 countries participated in semi-structured interviews to define the steps and technique of open appendectomy using cognitive task analysis. Using this input, our Academic Model Providing Access to Healthcare surgical team developed a curriculum, including a simulator and feedback mechanism. Surgeons and surgical trainees from Kenya and the United States tested the simulator prototype and provided feedback for its refinement based on clarity, utility, and realism. RESULTS: Instructions for a self-constructed simulator were developed at the cost of 70 Kenyan shillings (0.64 US dollars). Fifteen surgeons and surgical residents gave feedback on the simulator and curriculum, and each was presented with an updated version based on feedback. Overall, the curriculum was clear, with each sub-step receiving a median score of ≥83.5 out of 100 for clarity; however, through iterative design, the utility of sub-steps on the simulator improved. CONCLUSION: A comprehensive open appendectomy curriculum, including a low-cost appendectomy simulator model, was developed and refined using surgeon feedback. Such curricula may benefit trainees in low-resource settings who may otherwise have limited access to quality training material.

Gender Differences in Insurance, Surgical Admissions and Outcomes at a Kenyan Referral Hospital.

INTRODUCTION: Gender is an important factor in determining access to healthcare resources. Women face additional barriers, especially in low- and middle-income countries. Surgical costs can be devastating, which can exacerbate engendered disparities. Kenya's National Hospital Insurance Fund (NHIF) aims to achieve universal coverage and protect beneficiaries from catastrophic health expenditures. We examine gender differences in NHIF coverage, health-seeking behavior, and surgical outcomes at a tertiary care hospital in Eldoret, Kenya. MATERIALS AND METHODS: All patients ≥13 years admitted to the general surgery service at Moi Teaching and Referral Hospital from January 2018-July 2018 were enrolled. Health records were retrospectively reviewed for demographic data, clinical parameters, NHIF enrollment, and cost information. Descriptive analyses utilized Wilcoxon Rank Sum, Pearson's Chi-square, and Fisher's Exact tests. RESULTS: 366 patients were included for analysis. 48.6% were enrolled in NHIF with significant female predominance (64.8% versus 37.9%, P < 0.0001). Despite differing coverage rates, male and female patients underwent surgery and suffered in-hospital mortality at similar rates. However, women only comprised 39.6% of admissions and were significantly more likely to delay care (median 60 versus 7 days, P < 0.0001), be diagnosed with cancer (26.6% versus 13.2%, P = 0.0024), and require a palliative procedure for cancer (44.1% versus 13.0%, P = 0.013). CONCLUSION: Many financial and cultural barriers exist in Kenya that prevent women from accessing healthcare as readily as men, persisting despite higher rates of NHIF coverage amongst female patients. Investigation into extra-hospital costs and social disempowerment for women may elucidate key needs for achieving health equity.