Learner Milestones to Guide Decolonial Global Health Education.

The current movement to 'decolonize' global health aims to both dismantle colonial frameworks that perpetuate inequity and racism, as well as to rebuild and uplift structures and systems that celebrate indigeneity. However, it is critical to recognize that teaching decoloniality within global health education is more than just the acknowledgement that there are key paradigms missing from current global health education. It is imperative to have a methodology to hold ourselves and our learners accountable to progress in practices and ideals that promote equity-based praxis. In this paper, we propose the creation of a tool to assess learner levels and their progression over time in both recognizing the impacts of colonialism and acting to transform their own global health praxis towards equity and decoloniality. We developed a model to illustrate an increasing scope and impact of decolonial and global health equity praxis. We hypothesize through this model that the way in which learners engage with power dynamics and structural advocacy at each level is essential to describing learner stages. Based on extensive literature review, existing curricular frameworks, global partner discussion(s), feedback on our pilot curriculum, and adaptation of philosophical theory, these learner milestones were conceptualized. We discuss the inherent challenges in assessment of the complex mix of knowledge, attitude and skills described in these milestones with the understanding that any such assessment would always be formative, as we all continue learning how to do better. We hope these milestones can be utilized to promote critical transformational change in the field of global health. This requires deep self-reflection and examination of existing structures of oppression followed by intentional reparative actions to embody decoloniality in our praxis and advocacy and reimagine global health based on equity and local leadership.

The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting.

INTRODUCTION: Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings. METHODS: The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from "strongly disagree" to "strongly agree"). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC. RESULTS: Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the "share information" item was statistically significant. CONCLUSION: Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.

Validation of a wearable biosensor device for vital sign monitoring in septic emergency department patients in Rwanda.

OBJECTIVE: Critical care capabilities needed for the management of septic patients, such as continuous vital sign monitoring, are largely unavailable in most emergency departments (EDs) in low- and middle-income country (LMIC) settings. This study aimed to assess the feasibility and accuracy of using a wireless wearable biosensor device for continuous vital sign monitoring in ED patients with suspected sepsis in an LMIC setting. METHODS: This was a prospective observational study of pediatric (≥2 mon) and adult patients with suspected sepsis at the Kigali University Teaching Hospital ED. Heart rate, respiratory rate and temperature measurements were continuously recorded using a wearable biosensor device for the duration of the patients' ED course and compared to intermittent manually collected vital signs. RESULTS: A total of 42 patients had sufficient data for analysis. Mean duration of monitoring was 32.8 h per patient. Biosensor measurements were strongly correlated with manual measurements for heart rate (r = 0.87, p < 0.001) and respiratory rate (r = 0.75, p < 0.001), although were less strong for temperature (r = 0.61, p < 0.001). Mean (SD) differences between biosensor and manual measurements were 1.2 (11.4) beats/min, 2.5 (5.5) breaths/min and 1.4 (1.0)°C. Technical or practical feasibility issues occurred in 12 patients (28.6%) although were minor and included biosensor detachment, connectivity problems, removal for a radiologic study or exam, and patient/parent desire to remove the device. CONCLUSIONS: Wearable biosensor devices can be feasibly implemented and provide accurate continuous heart rate and respiratory rate monitoring in acutely ill pediatric and adult ED patients with sepsis in an LMIC setting.

Rapid cycle deliberate practice vs. traditional simulation in a resource-limited setting.

BACKGROUND: We sought to develop a low-fidelity simulation-based curriculum for pediatric residents in Rwanda utilizing either rapid cycle deliberate practice (RCDP) or traditional debriefing, and to determine whether RCDP leads to greater improvement in simulation-based performance and in resident confidence compared with traditional debriefing. METHODS: Pediatric residents at the Centre Hospitalier Universitaire de Kigali (CHUK) were randomly assigned to RCDP or traditional simulation and completed a 6 month-long simulation-based curriculum designed to improve pediatric resuscitation skills. Pre- and post- performance was assessed using a modified version of the Simulation Team Assessment Tool (STAT). Each video-taped simulation was reviewed by two investigators and inter-rater reliability was assessed. Self-confidence in resuscitation, pre- and post-simulation, was assessed by Likert scale survey. Analyses were conducted using parametric and non-parametric testing, ANCOVA and intra-class correlation coefficients (ICC). RESULTS: There was a 21% increase in pre- to post-test performance in both groups (p < 0.001), but no difference between groups (mean difference - 0.003%; p 0.94). Inter-rater reliability was exceptional with both pre and post ICCs ≥0.95 (p < 0.001). Overall, self-confidence scores improved from pre to post (24.0 vs. 30.0 respectively, p < 0.001), however, the there was no difference between the RCDP and traditional groups. CONCLUSIONS: Completion of a six-month low-fidelity simulation-based curriculum for pediatric residents in Rwanda led to statistically significant improvement in performance on a simulated resuscitation. RCDP and traditional low-fidelity simulation-based instruction may both be valuable tools to improve resuscitation skills in pediatric residents in resource-limited settings.

Provisional Validation of a Pediatric Early Warning Score for Resource-Limited Settings.

BACKGROUND AND OBJECTIVES: The use of Pediatric Early Warning Scores is becoming widespread to identify and rapidly respond to patients with deteriorating conditions. The ability of Pediatric Early Warning Scores to identify children at high risk of deterioration or death has not, however, been established in resource-limited settings. METHODS: We developed the Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) on the basis of expert opinion and existing scores. The PEWS-RL was derived from 6 equally weighted variables, producing a cumulative score of 0 to 6. We then conducted a case-control study of admissions to the pediatrics department of the main public referral hospital in Kigali, Rwanda between November 2016 and March 2017. We defined case patients as children fulfilling the criteria for clinical deterioration, who were then matched with controls of the same age and hospital ward. RESULTS: During the study period, 627 children were admitted, from whom we selected 79 case patients and 79 controls. For a PEWS-RL of ≥3, sensitivity was 96.2%, and specificity was 87.3% for identifying patients at risk for clinical deterioration. A total PEWS-RL of ≥3 was associated with a substantially increased risk of clinical deterioration (odds ratio 129.3; 95% confidence interval 38.8-431.6; P <.005). CONCLUSIONS: This study reveals that the PEWS-RL, a simple score based on vital signs, mental status, and presence of respiratory distress, was feasible to implement in a resource-limited setting and was able to identify children at risk for clinical deterioration.

Predictors of prescription filling after visits to the pediatric emergency department.

OBJECTIVE: The study's objective was to describe readily identifiable predictors of filling medication prescriptions after discharge from the pediatric emergency department (PED). METHODS: The study was a prospective cohort study of caregivers of children aged 0 to 17 years, discharged from the PED of an urban safety net hospital with a medication prescription. Prescription filling was confirmed by direct contact with pharmacies. Logistic regression was used to estimate the association between baseline characteristics and prescription filling. RESULTS: Overall, 36 (32%) of 111 families did not fill their children's prescriptions. We found no association between any predictors of interest and prescription filling. In the patient attributes domain, neither English as one's nondominant language (adjusted odds ratio [aOR], 0.72; 95% confidence interval [CI], 0.25-2.10) nor low health literacy (aOR, 0.78; 95% CI, 0.17-3.62) was associated with prescription filling. In the patient-provider interaction domain, poor physician-family communication (aOR, 1.52; 95% CI, 0.50-4.61), lack of trust in the medical provider (aOR, 0.68; 95% CI, 0.24-1.77), and caregiver disagreement with the treatment plan (aOR, 0.81; 95% CI, 0.14-4.92) had no association with prescription filling. In the patient-health system interaction domain, concern that the prescription would be unaffordable (aOR, 1.30; 95% CI, 0.48-3.53) and lack of an identified primary care physician for the child (aOR, 0.29; 95% CI, 0.08-1.04) were not associated with filling the prescriptions. CONCLUSIONS: Among a low-income urban population, approximately one third of families do not fill prescriptions for their children after discharge from the PED. We were unable to predict which families would fill prescriptions and which would not.