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.

Demographics and medical school exposures to rural health influence future practice.

BACKGROUND: One-fifth of the US population lives in rural areas. A record number of rural hospitals have closed, creating increased burdens on regional centers and delays in care. This study aimed to assess medical student perceptions of rural surgery and health care, and to elucidate influential factors for future practice. METHODS: We administered a survey to medical schools throughout Indiana, Illinois, and Michigan. The survey was designed and evaluated by a survey content expert and piloted among a group of students. Student and faculty liaisons disseminated the survey between February and May 2021. Descriptive analysis of data was completed using Stata v.16.1 (StataCorp, LLC, College Station, TX). RESULTS: The respondents included 700 medical students; 59.5% were female, with an equal distribution across medical school classes. More than 98% of students believe we "lack" or "are in great need of" rural health care providers, as well as rural surgeons; however, more than half of the students did not agree that the rural workforce is declining. Only 15.7% of students reported an interest in "pursuing a future career in a rural setting." Students with exposure to rural health care, coming from a rural hometown, or having a dependent had a positive association with interest in pursuing rural practice. CONCLUSION: Although students are aware of the lack of rural surgeons and health care providers, there remains an educational deficit. Expanding exposure to rural health care and surgery while in medical school may increase the number of students interested in pursuing a career in a rural setting, potentially shrinking the rural workforce gap.

Uncovering the Overlap of Global and Domestic Rural Surgery for Medical Trainees.

INTRODUCTION: Medical trainees who participate in global rotations demonstrate improved cultural sensitivity, increased involvement in humanitarian efforts, and ability to adapt to limited resources. The global coronavirus pandemic halted global rotations for medical trainees. Domestic rural surgery (DRS) may offer a unique alternative. We aimed to understand medical students' perceptions of the similarities and differences between global surgery and DRS and how students' priorities impact career choices. METHODS: An electronic survey was administered at eleven medical training institutions in Indiana, Illinois, and Michigan in spring 2021. Mixed methods analysis was performed for students who reported an interest in global surgery. Quantitative analysis was completed using Stata 16.1. RESULTS: Of the 697 medical student respondents, 202 were interested in global surgery. Of those, only 18.3% were also interested in DRS. Students interested in DRS had more rural exposures. Rural exposures associated with DRS interest were pre-clinical courses (P = 0.002), clinical rotations (P = 0.045), and rural health interest groups (P < 0.001). Students interested in DRS and those unsure were less likely to prioritize careers involving teaching or research, program prestige, perceived career advancement, and well-equipped facilities. The students who were unsure were willing to utilize DRS exposures. CONCLUSIONS: Students interested in global surgery express a desire to practice in low-resource settings. Increased DRS exposures may help students to understand the overlap between global surgery and DRS when it comes to working with limited resources, achieving work-life balance and practice location.

The role of community health workers in the surgical cascade: a scoping review.

BACKGROUND: Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade. METHODS: We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data. RESULTS: The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event. CONCLUSION: While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.

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.

Use of a Novel Trigger Tool to Identify Palliative Care Needs in Surgical Patients at a National Referral Hospital in Kenya: A Pilot Study.

Background: Addressing unmet palliative care needs in high-risk surgical patients in low- and middle-income countries must include innovative approaches to limitations in personnel and culturally acceptable assessment modalities. Objectives: We assessed the utility of a novel seven-item "Step-1" trigger tool in identifying surgical patients who may benefit from palliative care. Design: All adult patients (≥18 years) on general surgery, neurosurgery, and orthopedic surgery wards were enrolled over a four-month period. Setting/Subjects: This study took place at Moi Teaching and Referral Hospital (MTRH), one of two Kenyan national referral hospitals. Measurements: The "Step-1" trigger tool was administered, capturing provider estimates of prognosis, cancer history, social barriers, admission frequency, hospice history, symptom burden, and functional decline/wasting. A cut-point of ≥3 positive factors was selected, indicating a patient may benefit from palliative care. Results: A total of 411 patients were included for analysis. Twenty-five percent (n = 102) of patients had scores ≥3. The cut-point of ≥3 was significantly associated with identifying high-risk patients (HRP; χ2 = 32.3, p < 0.01), defined as those who died or were palliatively discharged, with a sensitivity and specificity of 63.9% and 78.9%, respectively. Survey questions with the highest overall impact included: "Would you be not surprised if the patient died within 12 months?," "Are there uncontrolled symptoms?," and "Is there functional decline/wasting?" Conclusions: This pilot study demonstrates that the "Step-One" trigger tool is a simple and effective method to identify HRP in resource-limited settings. Although this study identified three highly effective questions, the seven-question assessment is flexible and can be adapted to different settings.