Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study.

INTRODUCTION: There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. OBJECTIVES: to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. METHODS: A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. RESULTS: 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. CONCLUSION: LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.

Closing the communication gap in neonatal inter-hospital transfer: a neonatal referral form for resource-limited settings - a modified e-Delphi-consensus study.

Background: Standardised neonatal referral forms (NRFs) facilitate effective communication between healthcare providers and ensure continuity of care between facilities, which are essential for patient safety. We sought to determine the essential data items, or core clinical information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings (Rounds 1 to 3) and to create an NRF suitable for our setting (Round 4). Methods: We conducted an international, four-round, modified Delphi-consensus study. Round-1 was a literature and internet search to identify existing NRFs. In Round-2 and -3, participants were Rwandan clinicians and international paediatric healthcare practitioners who had worked in Rwanda in the five years before the study. These participants evaluated the draft items and proposed additional items to be included in an NRF. Round-4 focused on creating the NRF and used five focus groups of Rwandan general practitioners at district hospitals. Results: We identified 16 pre-existing NRFs containing 125 individual items. Of these, 91 items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round-3, participants scored items for importance, and 57 items met the final consensus criteria. In Round-4, 29 general practitioners took part in five focus groups; a total of 16 modifications were utilised to finalise the NRF. Conclusions: We generated a novel, robust, NRF that may be readily employed in resource-limited settings to communicate the essential clinical information to accompany a neonate requiring inter-hospital transfer.

Medical student satisfaction and confidence in simulation-based learning in Rwanda - Pre and post-simulation survey research.

INTRODUCTION: Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, comfort with undertaking taught tasks, inter-professional communication, teamwork and teaching skills. This study aimed to evaluate Rwandan medical students' attitudes, satisfaction and confidence level with SBL. METHODS: Fifth year medical students at the University of Rwanda were given a short course on paediatric acute care using simulation. The simulation sessions were locally developed cases based on the pRRAPID materials, developed at the University of Leeds (UK). Equipment included low fidelity infant mannequins, basic airway devices, IV access, and monitoring. A four-part, Likert-scale questionnaire was distributed to medical students before and after their four-week simulation program. RESULTS: 57 pre-simulation and 49 post-simulation questionnaires were completed. Confidence in skills increased in all fifteen domains of the questionnaire with the total skill confidence score rising from 44.0 (±12.3) to 56.2 (±8.8) after the simulation-based intervention (p < 0.001). Satisfaction and attitudes towards simulation-based learning in this setting were very positive. CONCLUSION: The simulation-based intervention was well received by students in this setting. Satisfaction was high and the simulation exercise increased the students' confidence. Previous research has demonstrated that SBL is effective and the results of this study now demonstrate that it is well received in our setting. As we move from knowledge-based education to a competency-based education culture, faculties in this setting should invest in providing SBL opportunities throughout the medical school curriculum.

Peer-teaching at the University of Rwanda - a qualitative study based on self-determination theory.

BACKGROUND: Peer-teaching is an educational format in which one student teaches one, or more, fellow students. Self-determination theory suggests that intrinsic motivation increases with the enhancement of autonomy, competence and relatedness. AIMS: This qualitative study sought to explore and better understand the lived experiences, attitudes and perceptions of medical students as peer-teachers at the University of Rwanda when participating in a peer-learning intervention in the pediatric department. METHODS: Students participated in a 3-h peer-taught symposium, supervised by a pediatric specialist or resident. Students worked in small groups to deliver a short didactic presentation related to acute illness in children. The symposium prepared the students for simulation-based teaching activities. In-depth, semi-structured, interviews were then employed to explore the students' experiences of the peer-teaching symposium. We specifically aimed to scaffold the analysis of these experiences on the themes of autonomy, competence and relatedness. RESULTS: Saturation was achieved after interviews with ten students. Students described developing their own autonomous learning strategies, but despite developing this autonomy had a desire for support in the delivery of the sessions. Competence was developed through enhanced learning of the material, developing teaching skills and confidence in public speaking. Students valued the different aspects of relatedness that developed through preparing and delivering the peer-teaching. Several other themes were identified during the interviews, which are not described here, namely; i. Satisfaction with peer-teaching; ii. Peer-teaching as a concept; iii. Practical issues related to the peer-teaching session, and iv. Teaching style from faculty. CONCLUSIONS: This is the first study to assess peer-learning activities in Rwanda. It has used qualitative methods to deeply explore the lived experiences, attitudes and perceptions of medical students. The peer-teaching strategy used here demonstrates the potential to enhance intrinsic motivation while increasing knowledge acquisition and teaching skills. We postulate that students in resource-limited settings, similar to Rwanda, would benefit from peer-teaching activities, and in doing so could enhance their intrinsic motivation.

Antibiotic prescribing practices in three neonatology units in Kigali, Rwanda. - an observational study.

INTRODUCTION: There is limited published data on antibiotic use in neonatal units in resource-poor settings. OBJECTIVES: This study sought to describe antibiotic prescribing practices in three neonatology units in Kigali, Rwanda. METHODS: A multi-center, cross-sectional study conducted in two tertiary and one urban district hospital in Kigali, Rwanda. Participants were neonates admitted in neonatology who received a course of antibiotics during their admission. Data collected included risk factors for neonatal sepsis, clinical signs, symptoms, investigations for neonatal sepsis, antibiotics prescribed, and the number of deaths in the included cohort. RESULTS: 126 neonates were enrolled with 42 from each site. Prematurity (38%) followed by membrane rupture more than 18 hours (25%) were the main risk factors for neonatal sepsis. Ampicillin and Gentamicin (85%) were the most commonly used first-line antibiotics for suspected neonatal sepsis. Most neonates (87%) did not receive a second-line antibiotic. Cefotaxime (11%), was the most commonly used second-line antibiotic. The median duration of antibiotic use was four days in all surviving neonates (m=113). In neonates with negative blood culture and normal C-reactive protein (CRP), the median duration of antibiotics was 3.5 days; and for neonates, with positive blood cultures, the median duration was 11 days. Thirteen infants died (10%) at all three sites, with no significant difference between the sites. CONCLUSION: The median antibiotic duration for neonates with normal lab results exceeded the recommended duration mandated by the national neonatal protocol. We recommend the development of antibiotic stewardship programs in neonatal units in Rwanda to prevent the adverse effects which may be caused by inappropriate or excessive use of antibiotics.

What topics should we teach the parents of admitted neonates in the newborn care unit in the resource-limited setting - a Delphi study.

BACKGROUND: In resource-limited settings, such as Rwanda, health care profession (HCP) to neonate ratios are low, and therefore caregivers play a significant role in providing care for their admitted neonates. To provide such Family Integrated Care, caregivers need knowledge, skills, and confidence. The objective of this study was to identify consensus from key stakeholders regarding the priority topics for a "parental neonatal curriculum." METHODS: A three-round Delphi-study was conducted. During Round-1, face-to-face interviews were undertaken and responses coded and categorized into themes. In Round-2, participants were presented with Round-1 feedback and asked to provide additional topics in respective themes. In Round-3, respondents were asked to rank the importance of these items using a 9-point Likert scale. RESULTS: Ten, 36 and 40 stakeholders participated in Rounds-1, - 2 and - 3 respectively, including parents, midwives, nurses and physicians. Twenty and 37 education topics were identified in Rounds-1 and -2 respectively. In Round-3 47 of the 57 presented outcomes met pre-defined criteria for inclusion in the "parental neonatal curriculum." CONCLUSION: We describe a "parental neonatal curriculum," formed using robust consensus methods, describing the core topics required to educate parents of neonates admitted to a newborn care unit. The curriculum has been developed in Rwanda and is relevant to other resource-limited settings.

Establishing a neonatal database in a tertiary hospital in Rwanda - an observational study.

Background: Monitoring and evaluation is vital in the quest to improve the quality of care and to reduce the morbidity and mortality of neonates in a resource-limited setting. Databases offer several advantages such as data on large cohorts of neonates and from multiple centres. Aim: To establish a minimal dataset neonatal database in Kigali, Rwanda and to assess the quality and timing of the data entry process. Secondary objectives were to describe survival rates and associated risk factors. Methods: A cross-sectional, observational study was undertaken at a tertiary hospital in Kigali, Rwanda. The Rwanda Neonatal Data Collection Form was designed specifically for the database, based on the Vermont-Oxford Network neonatal data-collection tool with locally relevant amendments. All admitted neonates were enrolled during the study period of 2011-2017 with ongoing data-collection. Infants were recruited and data collected prospectively and cross-checked retrospectively with the inclusion of basic data on neonates who were not initially recruited prospectively. Results: 3391 analysable cases were recruited: 1420 prospective and 1971 retrospective cases. Prospective data collection peaked at 90%. Data entry was not always complete with data-points left blank with only 21% having adequate data available (0-25% missing). All-cause mortality during the study period was 16% and annual mortality ranged from 12% to 24%. On multivariate analysis, place of birth (AOR 2.17), small-for-gestational-age (AOR 2.05) and gestational age were all positively associated with survival. Conclusions: An academic setting in a low- or middle-income country can create and maintain a neonatal database without funding and produce a wealth of actionable results. Throughout the process, there were considerable challenges which must be addressed if such a database is to be optimised, maintained and created in other clinical sites. Abbreviations: CHUK: Centre Hospitalier et Universitaire de Kigali (University Teaching Hospital of Kigali); CPAP: continuous positive airway pressure; HCP: Healthcare professional; HRH, Human Resources for Health Programme; LMIC: low- and middle-income countries; MeSH: Medical subject headings; MoH: Ministry of Health; NAR: Newborn admission record; QI: Quality improvement; REDCap: Research electronic data capture; RNDB: Rwanda neonatal database; RNDCF: Rwanda neonatal data collecion form; SGA: Small for gestational age; STROBE: Strengthening the reporting of observational studies in epidemiology; VON: The Vermont-Oxford Network.

Discovering Students' Personalised Uses of a Paediatrics Acute Care E-book - a Qualitative study.

This article was migrated. The article was marked as recommended. Background: Medical educators are increasingly developing and recommending e-books to supplement students' learning. Despite this, there is a gap in the literature surrounding E-book developers' understanding of how students can personalize an e-book for multiple different purposes. This qualitative research project aimed to explore students' experiences of using a pediatric acute care E-book (pRRAPID) within a spiral, multi-method teaching package. The researchers aimed to get an insight into the ways that learners used E-books outside of the classroom. Methods: Three focus groups were conducted with 12 fourth-year medical students who had completed a pediatric acute care course. Students were invited to discuss their use of the E-book during the course. Thematic analysis was conducted on the transcripts to identify codes in the data; these were grouped to determine the overarching themes. Results: Students outlined five different ways that they personalized the use of the E-book. Three of these were related to uses of the E-book within the context of the pediatric acute care course; students using the E-book to prepare for a formal teaching session ("Flipped classroom"),students using the E-book as a workbook (going from start to end) and students using the E-book to prepare for an exam. The other two themes related to the use of the E-book outside of the acute care course; students using the E-book as a resource "on the go" and students using the E-book within clinical practice. Conclusions This qualitative study outlines how an educational resource can be utilized in numerous different ways in order to satisfy the needs of the student. Focus-group participants outlined how important it was to engage with the students, as the primary stakeholder, when developing an E-book.