Sepsis in two hospitals in Rwanda: A retrospective cohort study of presentation, management, outcomes, and predictors of mortality.

PURPOSE: Few studies have assessed the presentation, management, and outcomes of sepsis in low-income countries (LICs). We sought to characterize these aspects of sepsis and to assess mortality predictors in sepsis in two referral hospitals in Rwanda. MATERIALS AND METHODS: This was a retrospective cohort study in two public academic referral hospitals in Rwanda. Data was abstracted from paper medical records of adult patients who met our criteria for sepsis. RESULTS: Of the 181 subjects who met eligibility criteria, 111 (61.3%) met our criteria for sepsis without shock and 70 (38.7%) met our criteria for septic shock. Thirty-five subjects (19.3%) were known to be HIV positive. The vast majority of septic patients (92.7%) received intravenous fluid therapy (median = 1.0 L within 8 hours), and 94.0% received antimicrobials. Vasopressors were administered to 32.0% of the cohort and 46.4% received mechanical ventilation. In-hospital mortality for all patients with sepsis was 51.4%, and it was 82.9% for those with septic shock. Baseline characteristic mortality predictors were respiratory rate, Glasgow Coma Scale score, and known HIV seropositivity. CONCLUSIONS: Septic patients in two public tertiary referral hospitals in Rwanda are young (median age = 40, IQR = 29, 59) and experience high rates of mortality. Predictors of mortality included baseline clinical characteristics and HIV seropositivity status. The majority of subjects were treated with intravenous fluids and antimicrobials. Further work is needed to understand clinical and management factors that may help improve mortality in septic patients in LICs.

Promoting anaesthetisia providers' non-technical skills through the Vital Anaesthesia Simulation Training (VAST) course in a low-resource setting.

BACKGROUND: Short educational programmes are important in building global anaesthesia workforce capacity. The Vital Anaesthesia Simulation Training (VAST) course is a 3-day immersive simulation-based programme concentrating on core clinical challenges and non-technical skills required by anaesthesia providers in low-resource settings. METHODS: This mixed methods study prospectively evaluated the impact of VAST in Rwanda. Anaesthetists' Non-Technical Skills (ANTS) scores were quantitatively assessed for 30 course participants at three time points (pre-, post-, and 4 months after VAST). Qualitative data were gathered during focus groups (4 months after VAST) to learn of participants' experiences implementing new knowledge into clinical practice. RESULTS: The ANTS total scores improved from pre- (11.0 [2.3]) (mean [standard deviation]) to post-test (14.0 [1.6]), and improvements were maintained at retention (14.2 [1.7]). A similar pattern was observed when data were analysed using the four ANTS categories (all P<0.001). The key theme that emerged during focus group discussions was that the use of cognitive aids and clinical algorithms, repeated and reinforced across simulated scenarios, encouraged a systematic approach to patient care. The participants attributed the systematic approach to improving their problem-solving skills and confidence, particularly during emergencies. They found value in well-functioning teams and shared decision-making. After VAST, the participants described empowerment to advocate for better patient care and system improvement. CONCLUSIONS: VAST offers a simulation-based training to anaesthesia providers working in low-resource settings. Skills retention and self-reported application of learning into the workplace reflect the scope of impact of this training.

Low-Cost Simulation to Teach Anesthetists' Non-Technical Skills in Rwanda.

BACKGROUND: Safe anesthesia care is challenging in developing countries where there are shortages of personnel, drugs, equipment, and training. Anesthetists' Non-technical Skills (ANTS)-task management, team working, situation awareness, and decision making-are difficult to practice well in this context. Cesarean delivery is the most common surgical procedure in sub-Saharan Africa. This pilot study investigates whether a low-cost simulation model, with good psychological fidelity, can be used effectively to teach ANTS during cesarean delivery in Rwanda. METHODS: Study participants were anesthesia providers working in a tertiary referral hospital in Rwanda. Baseline observations were conducted for 20 anesthesia providers during cesarean delivery using the established ANTS framework. After the first observation set was complete, participants were randomly assigned to either simulation intervention or control groups. The simulation intervention group underwent ANTS training using low-cost high psychological fidelity simulation with debriefing. No training was offered to the control group. Postintervention observations were then conducted in the same manner as the baseline observations. RESULTS: The primary outcome was the overall ANTS score (maximum, 16). The median (range) ANTS score of the simulation group was 13.5 (11-16). The ANTS score of the control group was 8 (8-9), with a statistically significant difference (P = .002). Simulation participants showed statistically significant improvement in subcategories and in the overall ANTS score compared with ANTS score before simulation exposure. CONCLUSIONS: Rwandan anesthesia providers show improvement in ANTS practice during cesarean delivery after 1 teaching session using a low-cost high psychological fidelity simulation model with debriefing.

Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership.

Simulation replicates clinical experiences without patient risk; it remains uncommon in lower-income countries. We outline the creation of Rwanda's first centre for simulation and skills training. We secured funding for renovations, equipment and staff; curricula were developed, tested, and refined; local clinicians were trained to teach. In 13 months the centre provided 2,377 learning-encounters and 822 hours of training to Rwandan health care professionals. Our strategy represents an adaptable model for simulation and skills centre development in low-resources settings.

Non-technical skills of anaesthesia providers in Rwanda: an ethnography.

INTRODUCTION: Patient safety depends on excellent practice of anaesthetists' non-technical skills (ANTS). The ANTS framework has been validated in developed countries but there is no literature on the practice of ANTS in low-income countries. This study examines ANTS in this unexplored context. METHODS: This qualitative ethnographic study used observations of Rwandan anaesthesia providers and in-depth interviews with both North American and Rwandan anaesthesia providers to understand practice of ANTS in Rwanda. RESULTS: Communication is central to the practice of ANTS. Cultural factors in Rwanda, such as lack of assertiveness and discomfort taking leadership, and the strains of working in a resource-limited environment hinder the unfettered and focused communication needed for excellent anaesthesia practice. CONCLUSION: Despite the challenges, anaesthesia providers are able to coordinate activities when good communication is actively encouraged. Future teaching interventions should address leadership and communication skills through encouraging both role definition and speaking up for patient safety.