The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial.

BACKGROUND: The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)-led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. OBJECTIVE: This trial assesses whether CHW's use of a mobile health (mHealth)-facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. METHODS: A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. RESULTS: The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). CONCLUSIONS: Home-based post-c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. TRIAL REGISTRATION: ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399.

Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers.

Background: We aimed to develop and validate a screening algorithm to assist community health workers (CHWs) in identifying surgical site infections (SSIs) after cesarean section (c-section) in rural Africa. Methods: Patients were adult women who underwent c-section at a Rwandan rural district hospital between March and October 2017. A CHW administered a nine-item clinical questionnaire 10 ± 3 days post-operatively. Independently, a general practitioner (GP) administered the same questionnaire and assessed SSI presence by physical examination. The GP's SSI diagnosis was used as the gold standard. Using a simplified Classification and Regression Tree analysis, we identified a subset of screening questions with maximum sensitivity for the GP and CHW and evaluated the subset's sensitivity and specificity in a validation dataset. Then, we compared the subset's results when implemented in the community by CHWs with health center-reported SSI. Results: Of the 596 women enrolled, 525 (88.1%) completed the clinical questionnaire. The combination of questions concerning fever, pain, and discolored drainage maximized sensitivity for both the GPs (sensitivity = 96.8%; specificity = 85.6%) and CHWs (sensitivity = 87.1%; specificity = 73.8%). In the validation dataset, this subset had sensitivity of 95.2% and specificity of 83.3% for the GP-administered questions and sensitivity of 76.2% and specificity of 81.4% for the CHW-administered questions. In the community screening, the overall percent agreement between CHW and health center diagnoses was 81.1% (95% confidence interval: 77.2%-84.6%). Conclusions: We identified a subset of questions that had good predictive features for SSI, but its sensitivity was lower when administered by CHWs in a clinical setting, and it performed poorly in the community. Methods to improve diagnostic ability, including training or telemedicine, must be explored.

A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda.

OBJECTIVE: Breast cancer incidence is rising for women in low and middle income country (LMIC)s. Growing the health care workforce trained in clinical breast exam (CBE) is critical to mitigating breast cancer globally. We developed a CBE simulation training course and determined whether training on a low-fidelity (LF) simulation model results in similar skill acquisition as training on high-fidelity (HF) models in Rwanda. DESIGN: A single-center randomized educational crossover trial was implemented. A preintervention baseline exam (exam 1), followed by a lecture series (exam 2), and training sessions with assigned simulation models was implemented (exam 3)-participants then crossed over to their unassigned model (exam 4). The primary outcome of this study determined mean difference in CBE exam scores between HF and LF groups. Secondary outcomes identified any provider level traits and changes in overall scores. SETTING: The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from July 2014 to March 2015 PARTICIPANTS: Medical students, residents in surgery, obstetrics and gynecology, and internal medicine residents participated in a 1-day CBE simulation training course. RESULTS: A total of 107 individuals were analyzed in each arm of the study. Mean difference in exam scores between HF and LF models in exam 1 to 4 was not significantly different (exam 1 0.08 standard error (SE) = 0.47, p = 0.42; exam 2 0.86, SE = 0.69, p = 0.16; exam 3 0.03, SE = 0.38, p = 0.66; exam 4 0.10 SE = 0.37, p = 0.29). Overall exam scores improved from pre- to post-intervention. CONCLUSIONS: Mean difference in exams scores were not significantly different between participants trained with HF versus LF models. LF models can be utilized as cost effective teaching tools for CBE skill acquisition, in resource poor areas.

A Randomized Cross-Over Trial Focused on Breast Core Needle Biopsy Skill Acquisition and Safety Using High Fidelity Versus Low Fidelity Simulation Models in Rwanda.

OBJECTIVE: Breast cancer is the most common cancer diagnosed in low and middle-income countries. Growing the number of health care personnel trained in diagnostic procedures like breast core needle biopsy (BCNB) is critical. We developed a BCNB simulation-training course that evaluated skill acquisition, confidence, and safety, comparing low-cost low fidelity (LF) models to expensive high fidelity (HF) models. DESIGN: A single-center randomized education crossover trial was implemented. Participants were randomized to HF or LF groups. A preintervention baseline exam followed by lectures and training sessions with a HF or LF model was implemented. A postintervention simulation exam was conducted, and participants crossed over to the other simulation model. SETTING: The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from October 2014 to March 2015. PARTICIPANTS: Residents training in surgery or obstetrics and gynecology participated in a 1-day BCNB training course. RESULTS: A total of 36 residents were analyzed, 19 in the HF arm and 17 in the LF arm. Mean difference in exam scores for HF and LF groups in the baseline exam (exam 1) (0.067, p = 0.94, standard error [SE] of 1.57) postintervention exam (exam 2) (1.85, SE 1.46, p = 0.33), and the crossover exam (exam 3) (4.39, SE = 1.90, p = 0.11) were not significantly different between HF and LF. Overall exam scores improved from pre- to postintervention. CONCLUSIONS: Our results indicate that mean difference in exams scores were not significantly different between residents trained with HF versus LF models. In resources poor areas-LF models can be utilized as effective teaching tools for skill acquisition for diagnostic surgical procedures.

Epidemiologic Characteristics of Pediatric Trauma Patients Receiving Prehospital Care in Kigali, Rwanda.

BACKGROUND: Pediatric trauma is a significant public health problem in resource-constrained settings; however, the epidemiology of injuries is poorly defined in Rwanda. This study describes the characteristics of pediatric trauma patients transported to the emergency department (ED) of the Centre Hospitalier Universitaire de Kigali by emergency medical services in Kigali, Rwanda. METHODS: This cohort study was conducted at the Centre Hospitalier Universitaire de Kigali from December 2012 to February 2015. Patients 15 years or younger brought by emergency medical services for injuries to the ED were included. Prehospital and hospital-based data on demographics, injury characteristics, treatments, and outcomes were gathered. RESULTS: Data from 119 prehospital patients were accrued, with corresponding hospital data for 64 cases. The median age was 9.5 years, with most patients being male (67.2%). Injured children were most frequently brought from a street setting (69.6%). Road traffic injuries accounted for 69.4% of all mechanisms, with more than two thirds due to pedestrians being struck. Extremity trauma was the most common region of injury (53.1%), followed by craniofacial (46.8%). The most frequent ED interventions were analgesia (66.1%) and intravenous fluids (43.6%). Half of the 16 obtained head computed tomography scans demonstrated acute pathology. Twenty-eight patients (51.9%) were admitted, with 57.1% requiring surgery and having a median in-hospital care duration of 9 days (range, 1-122 days). CONCLUSIONS: In this cohort of Rwandan pediatric trauma patients, injuries to the extremities and craniofacial regions were most common. Theses traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of the associated injury patterns, may be beneficial in the Rwandan setting.

Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC).

OBJECTIVE: To identify the critical nontechnical skills (NTS) required for high performance in variable-resource contexts (VRC). BACKGROUND: As surgical training and capacity increase in low- and middle-income countries (LMICs), new strategies for improving surgical education and care in these settings are required. NTS are critical for high performance in surgery around the world. However, the essential NTS used by surgeons operating in LMICs to overcome the challenges specific to their contexts have never been described. METHOD: Using a constructivist grounded theory approach, 52 intraoperative team observations as well as 34 critical incident interviews with surgical providers (surgeons, anesthetists, and nurses) were performed at the 4 tertiary referral hospitals in Rwanda. Interview transcripts and field notes from observations were analyzed using line-by-line coding to identify emerging themes until thematic saturation was achieved. RESULTS: Four skill categories of situation awareness, decision-making, communication/teamwork, and leadership emerged. This provided the framework for a contextually informed skills taxonomy consisting of 12 skill elements with examples of specific behaviors indicative of high performance. While the main skill categories were consistent with those encountered in high-income countries, the specific behaviors associated with these skills often focused on overcoming the frequently encountered variability in resources, staff, systems support, and language in this context. CONCLUSION: This is the first description of the critical nontechnical skills, and associated example behaviors, used by surgeons in a VRC to overcome common challenges to safe and effective surgical patient care. Improvements in the NTS used by surgeons operating in VRCs have the potential to improve surgical care delivery worldwide.

Global Health in the 21st Century: Equity in Surgical Training Partnerships.

INTRODUCTION: Safe and affordable surgical care has been recognized as an important component of global health. One of the challenges in providing safe and affordable surgical care is the shortage of trained surgical workforce. Partnerships have developed between institutions in high-income countries (HICs) and low- and middle-income countries (LMICs) to strengthen and expand surgical education in LMICs. As these relationships evolve, emphasis needs to focus on development of equitable, bilateral partnerships. METHODS: We reviewed different global surgery education partnerships to describe key components and features of successful partnerships. We then provide a framework for equitable global surgical training partnerships. RESULTS: Key features of equitable global surgical education partnerships included an alignment with local priorities, long term collaborations, and locally integrated, competency-based training. To develop a partnership, both parties must meet and perform a needs assessment of the LMIC institution and jointly agree how the partnership can best address these needs. Both the HIC and LMIC institutions must clearly define their goals and expectations. Ideally, a set of output measures will be defined to assess the success of the partnership. CONCLUSIONS: Improving surgical education in LMIC countries is an integral part of health equity in global surgery. Key components of equitable education partnerships focus on local ownership and long-term relationships. Each party needs to clearly define goals and expectations for the partnership. Equity is essential and unequal relationships must be avoided.

Laparoscopy in Rwanda: A National Assessment of Utilization, Demands, and Perceived Challenges.

BACKGROUND: Laparoscopy has proven to be feasible and effective at reducing surgical morbidity and mortality in low resource settings. In Rwanda, the demand for and perceived challenges to laparoscopy use remain unclear. METHODS: A mixed-methods study was performed at the four Rwandan national referral teaching hospitals. Retrospective logbook reviews (July 2014-June 2015) assessed procedure volume and staff involvement. Web-based surveys and semi-structured interviews investigated barriers to laparoscopy expansion. RESULTS: During the study period, 209 laparoscopic procedures were completed: 57 (27.3%) general surgery cases; 152 (72.7%) ob/gyn cases. The majority (58.9%, 125/209) occurred at the private hospital, which performed 82.6% of cholecystectomies laparoscopically (38/46). The three public hospitals, respectively, performed 25% (7/28), 15% (12/80), and 0% (denominator indeterminate) of cholecystectomies laparoscopically. Notably, the two hospitals with the highest laparoscopy volume relied on a single surgeon for more than 85% of cases. The four ob/gyn departments performed between 4 and 87 laparoscopic cases (mostly diagnostic). Survey respondents at all sites listed a dearth of trainers as the most significant barrier to performing laparoscopy (65.7%; 23/35). Other obstacles included limited access to training equipment and courses. Equipment and material costs, equipment functionality, and material supply were perceived as lesser barriers. Twenty-two interviews revealed widespread interest in laparoscopy, insufficient laparoscopy exposure, and a need for trainers. CONCLUSION: While many studies identify cost as the most prohibitive barrier to laparoscopy utilization in low resource settings, logbook review and workforce perception indicate that a paucity of trainers is currently the greatest obstacle in Rwanda.

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits.

BACKGROUND: Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training. METHODS: A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods. RESULTS: Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01). CONCLUSIONS AND RELEVANCE: Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

Using mobile health technology and community health workers to identify and refer caesarean-related surgical site infections in rural Rwanda: a randomised controlled trial protocol.

INTRODUCTION: Surgical site infections (SSIs) are a significant cause of morbidity and mortality in low-income and middle-income countries, where rates of SSIs can reach 30%. Due to limited access, there is minimal follow-up postoperatively. Community health workers (CHWs) have not yet been used for surgical patients in most settings. Advancements in telecommunication create an opportunity for mobile health (mHealth) tools to support CHWs. We aim to evaluate the use of mHealth technology to aid CHWs in identification of SSIs and promote referral of patients back to healthcare facilities. METHODS AND ANALYSIS: Prospective randomised controlled trial conducted at Kirehe District Hospital, Rwanda, from November 2017 to November 2018. Patients ≥18 years who undergo caesarean section are eligible. Non-residents of Kirehe District or patients who remain in hospital >10 days postoperatively will be excluded. Patients will be randomised to one of three arms. For arm 1, a CHW will visit the patient's home on postoperative day 10 (±3 days) to administer an SSI screening protocol (fever, pain or purulent drainage) using an electronic tablet. For arm 2, the CHW will administer the screening protocol over the phone. For both arms 1 and 2, the CHW will refer patients who respond 'yes' to any of the questions to a health facility. For arm 3, patients will not receive follow-up care. Our primary outcome will be the impact of the mHealth-CHW intervention on the rate of return to care for patients with an SSI. ETHICS AND DISSEMINATION: The study has received ethical approval from the Rwandan National Ethics Committee and Partners Healthcare. Results will be disseminated to Kirehe District Hospital, Rwanda Ministry of Health, Rwanda Surgical Society, Partners In Health, through conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03311399.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda.

BACKGROUND: The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty. METHODS: Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants' responses. RESULTS: Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45). CONCLUSIONS: General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

The Basic Surgical Skills Course in Sub-Saharan Africa: An Observational Study of Effectiveness.

BACKGROUND: The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa. METHODS: An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery. RESULTS: A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees. CONCLUSION: The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills.

Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum.

OBJECTIVE: A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety. DESIGN: The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety. SETTING: The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda. PARTICIPANTS: Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%). RESULTS: In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, p<0.01). All residents reported that the course would improve their ability to provide safer patient care, and 97.4% believed developing nontechnical skills would improve patient outcomes. CONCLUSIONS: Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global surgical safety.

Contextual Challenges to Safe Surgery in a Resource-limited Setting: A Multicenter, Multiprofessional Qualitative Study.

OBJECTIVES: Safe surgery should be available to all patients, no matter the setting. The purpose of this study was to explore the contextual-specific challenges to safe surgical care encountered by surgeons and surgical teams in many in low- and middle-income countries (LMICs), and to understand the ways in which surgical teams overcome them. BACKGROUND: Optimal surgical performance is highly complex and requires providers to integrate and communicate information regarding the patient, task, team, and environment to coordinate team-based care that is timely, effective, and safe. Resource limitations common to many LMICs present unique challenges to surgeons operating in these environments, but have never been formally described. METHODS: Using a grounded theory approach, we interviewed 34 experienced providers (surgeons, anesthetists, and nurses) at the 4 tertiary referral centers in Rwanda, to understand the challenges to safe surgical care and strategies to overcome them. Interview transcripts were coded line-by-line and iteratively analyzed for emerging themes until thematic saturation was reached. RESULTS: Rwandan-described challenges related to 4 domains: physical resources, human resources, overall systems support, and communication/language. The majority of these challenges arose from significant variability in either the quantity or quality of these domains. Surgical providers exhibited examples of resilient strategies to anticipate, monitor, respond to, and learn from these challenges. CONCLUSIONS: Resource variability rather than lack of resources underlies many contextual challenges to safe surgical care in a LMIC setting. Understanding these challenges and resilient strategies to overcome them is critical for both LMIC surgical providers and surgeons from HICs working in similar settings.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District.

IMPORTANCE: In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. OBJECTIVE: To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. MAIN OUTCOMES AND MEASURES: The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. RESULTS: Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. CONCLUSIONS AND RELEVANCE: The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Trauma care and referral patterns in Rwanda: implications for trauma system development.

BACKGROUND: Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. METHODS: We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ² and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. RESULTS: Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). CONCLUSION: To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions.

CONTEXTE: Les traumatismes demeurent l'une des principales causes de décès dans le monde. La mise au point de systèmes de traumatologie dans des milieux défavorisés pourrait toutefois contribuer à améliorer la situation. Notre étude avait pour objectif de décrire les interventions chirurgicales pratiquées sur les victimes de traumatismes dans un établissement de soins tertiaires de Kigali, au Rwanda, et d'évaluer les variations géographiques et les habitudes d'orientation des patients dans le domaine de la traumatologie. MÉTHODES: Nous avons évalué rétroactivement les données recueillies de façon prospective sur l'ensemble des interventions réalisées au plus grand centre hospitalier régional du Rwanda, le Centre hospitalier universitaire de Kigali (CHUK), du 1er juin au 1er décembre 2011 pour les diagnostics liés à des blessures. Nous avons eu recours au test χ² de Pearson et au test exact de Fisher pour comparer les cas issus de la province de Kigali à ceux provenant d'autres provinces. Nous avons en outre effectué des analyses géospatiales afin de mieux comprendre les habitudes d'orientation des patients. RÉSULTATS: Au cours des 6 mois de l'étude, 2758 interventions chirurgicales ont été pratiquées au CHUK, dont 653 (23,7 %) pour des traumatismes. La majorité des patients résidaient à l'extérieur de la capitale : 337 (58,0 %) d'entre eux avaient été transférés d'autres provinces, et 244 (42,0 %), d'ailleurs dans la province. Si la plupart des interventions chirurgicales étaient orthopédiques (489, soit 84,2 %), les patients d'autres provinces ont plus souvent subi des interventions générales que leurs compatriotes de la province de Kigali (28 sur 337, soit 8,3 %, par rapport à 10 sur 244, soit 4,1 %). CONCLUSION: À notre connaissance, il s'agit de la première étude mettant en lumière les variations géographiques de l'accès aux soins en traumatologie dans un pays à faible revenu et de la première description des interventions chirurgicales pratiquées sur des victimes de traumatismes dans un centre régional du Rwanda. Les travaux à venir devraient être axés sur le développement des systèmes de transport avant l'hospitalisation et entre les établissements, le renforcement des hôpitaux de district et l'augmentation du soutien aux centres régionaux.

Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda.

BACKGROUND: Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS: A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS: A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION: This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.

Associations with Perioperative Mortality Rate at a Major Referral Hospital in Rwanda.

BACKGROUND: Little is known about perioperative mortality in sub-Saharan Africa. The perioperative mortality rate (POMR) and associated factors at a major referral hospital in Rwanda were measured. METHODS: The operative activity at University Teaching Hospital of Kigali was evaluated through an operative database. As a part of this larger study, patient characteristics and outcomes were measured to determine areas for improvement in patient care. Data were collected on patient demographics, surgeon, diagnosis, and operation over a 12-month period. The primary outcome was POMR. Secondary outcomes were timing and hospital location of death. RESULTS: The POMR was 6 %. POMR in patients under 5 years of age was 10 %, 3 % in patients 5-14 years and 6 % in patients age >14 years. For emergency and elective operations, POMR was 9 and 2 %, respectively. POMR was associated with emergency status, congenital anomalies, repeat operations, referral outside Kigali, and female gender. Orthopedic procedures and age 5-14 years were associated with decreased odds of mortality. Forty-nine percent of deaths occurred in the post-operative recovery room and 35 % of deaths occurred within the first post-operative day. CONCLUSIONS: The POMR at a large referral hospital in Rwanda is <10 % demonstrating that surgery can save lives even in resource-limited settings. Emergency operations are associated with higher mortality, which could potentially be improved with faster identification and transfer from district hospitals. Nearly half of deaths occurred in the post-operative recovery room. Multidisciplinary audits of operative mortalities could help guide improvements in surgical care.

Vital Statistics: Estimating Injury Mortality in Kigali, Rwanda.

BACKGROUND: Globally, injury deaths largely occur in low- and middle-income countries. No estimates of injury associated mortality exist in Rwanda. This study aimed to describe the patterns of injury-related deaths in Kigali, Rwanda using existing data sources. METHODS: We created a database of all deaths reported by the main institutions providing emergency care in Kigali­four major hospitals, two divisions of the Rwanda National Police, and the National Emergency Medical Service--during 12 months (Jan­Dec 2012) and analyzed it for demographics, diagnoses, mechanism and type of injury, causes of death, and all-cause and cause-specific mortality rates. RESULTS: There were 2682 deaths, 57% in men, 67% in adults >18 year, and 16% in children <5 year. All-cause mortality rate was 236/100,000; 35% (927) were due to probable surgical causes. Injury-related deaths occurred in 22% (593/2682). The most common injury mechanism was road traffic crash (cause-specific mortality rate of 20/100,000). Nearly half of all injury deaths occurred in the prehospital setting (47%, n = 276) and 49% of injury deaths at the university hospital occurred within 24 h of arrival. Being injured increased the odds of dying in the prehospital setting by 2.7 times (p < 0.0001). CONCLUSIONS: Injuries account for 22% of deaths in Kigali with road traffic crashes being the most common cause.Injury deaths occurred largely in the prehospital setting and within the first 24 h of hospital arrival suggesting the need for investment in emergency infrastructure. Accurate documentation of the cause of death would help policy makers make data-driven resource allocation decisions.

Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda.

INTRODUCTION: Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d'Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital-hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. METHODS: A retrospective cohort study was conducted at University Teaching Hospital - Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU's prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. RESULTS: 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. CONCLUSION: A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.

INTRODUCTION: Les blessures comptent pour 9,6% de la mortalité dans le monde, affectant de manière disproportionnée les personnes vivant dans les pays à revenu faible et intermédiaire. Dans un effort pour améliorer la prise en charge des traumatismes au Rwanda, le ministère de la Santé a développé un service préhospitalier, le Service d'Aide Médicale Urgente (SAMU), et mis en place un programme de formation à la médecine d'urgence. Cependant, peu d'informations sont disponibles sur les patients bénéficiant d'une prise en charge préhospitalière et de soins d'urgence ou sur les résultats obtenus. L'objectif était de développer une base de données préhospitalière et hospitalière couplée afin d'évaluer les caractéristiques des patients, les mécanismes des blessures, l'utilisation des ressources préhospitalières et hospitalières et les résultats pour les patients blessés recevant des soins intensifs à Kigali, au Rwanda. MÉTHODES: Une étude de cohorte rétrospective a été menée à l'Hôpital universitaire de Kigali, principal centre de prise en charge des traumatismes au Rwanda. Des données ont été incluses sur tous les patients blessés transportés par le SAMU entre décembre 2012 et février 2015. La base de données préhospitalière a été couplée aux dossiers hospitaliers et les données ont été recueillies au moyen de protocoles standardisés par des archivistes formés. Les données démographiques, caractéristiques des blessures, soins intensifs, parcours hospitalier et résultats ont été inclus. RÉSULTATS: 1 668 patients ont été transportés pour des lésions traumatiques au cours de la période à l'étude. La majorité des patients étaient des hommes, à 77,7%. L'âge moyen était de 30 ans. Les collisions de véhicules motorisés étaient responsables de 75% des cas, 61,4% de ceux-ci impliquant des motos. 48,8% des patients souffraient de blessures au niveau de deux régions anatomiques ou plus. 40,1% des patients ont été hospitalisés, et 78,1% d'entre eux ont dû être opérés. Le taux de mortalité général était de 5,5%, près de la moitié des décès hospitaliers survenant au service des urgences. CONCLUSION: Une base de données préhospitalière et hospitalière couplée a fourni des informations épidémiologiques essentielles décrivant les patients en traumatologie dans un environnement caractérisé par de faibles ressources. Les traumatismes contondants liés à des collisions de véhicules motorisés impliquant des hommes jeunes constituaient la majorité des lésions traumatiques. Au sein de cette cohorte, le recours aux ressources hospitalières était élevé, ainsi que la mortalité. Ces données peuvent aider à guider la mise en œuvre d'interventions visant à améliorer la prise en charge des traumatismes dans le contexte rwandais.