Core sepsis-related competencies for medical students: an international consensus by Delphi technique.

BACKGROUND: Sepsis is a life-threatening condition which may arise from infection in any organ system and requires early recognition and management. Healthcare professionals working in any specialty may need to manage patients with sepsis. Educating medical students about this condition may be an effective way to ensure all future doctors have sufficient ability to diagnose and treat septic patients. However, there is currently no consensus on what competencies medical students should achieve regarding sepsis recognition and treatment. This study aims to outline what sepsis-related competencies medical students should achieve by the end of their medical student training in both high or upper-middle incomes countries/regions and in low or lower-middle income countries/regions. METHODS: Two separate panels from high or upper-middle income and low or lower-middle income countries/regions participated in a Delphi method to suggest and rank sepsis competencies for medical students. Each panel consisted of 13-18 key stakeholders of medical education and doctors in specialties where sepsis is a common problem (both specialists and trainees). Panelists came from all continents, except Antarctica. RESULTS: The panels reached consensus on 38 essential sepsis competencies in low or lower-middle income countries/regions and 33 in high or upper-middle incomes countries/regions. These include competencies such as definition of sepsis and septic shock and urgency of antibiotic treatment. In the low or lower-middle income countries/regions group, consensus was also achieved for competencies ranked as very important, and was achieved in 4/5 competencies rated as moderately important. In the high or upper-middle incomes countries/regions group, consensus was achieved in 41/57 competencies rated as very important but only 6/11 competencies rated as moderately important. CONCLUSION: Medical schools should consider developing curricula to address essential competencies, as a minimum, but also consider addressing competencies rated as very or moderately important.

Global critical care: a call to action.

Critical care is underprioritized. A global call to action is needed to increase equitable access to care and the quality of care provided to critically ill patients. Current challenges to effective critical care in resource-constrained settings are many. Estimates of the burden of critical illness are extrapolated from common etiologies, but the true burden remains ill-defined. Measuring the burden of critical illness is epidemiologically challenging but is thought to be increasing. Resources, infrastructure, and training are inadequate. Millions die unnecessarily due to critical illness. Solutions start with the implementation of first-step, patient care fundamentals known as Essential Emergency and Critical Care. Such essential care stands to decrease critical-illness mortality, augment pandemic preparedness, decrease postoperative mortality, and decrease the need for advanced level care. The entire healthcare workforce must be trained in these fundamentals. Additionally, physician and nurse specialists trained in critical care are needed and must be retained as leaders of critical care initiatives, researchers, and teachers. Context-specific research is mandatory to ensure care is appropriate for the patient populations served, not just duplicated from high-resourced settings. Governments must increase healthcare spending and invest in capacity to treat critically ill patients. Advocacy at all levels is needed to achieve universal health coverage for critically ill patients.

Using the World Society of Emergency Surgery (WSES) Triage Tool to Evaluate Timing of Emergency Surgery in Rwanda.

BACKGROUND: Access to timely and safe emergency general surgery remains a challenge in sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study has the following objectives: (1) to compare the actual time to surgery (aTTS) to the ideal time to surgery among patients undergoing emergency surgery and (2) to explore the use of home to emergency department time (HET) as a new measurement indicator for time from symptoms onset to admission at ED at a referral hospital. METHODS: We performed a retrospective review of emergency general surgery cases performed at the Centre Hospitalier Universitaire de Kigali in Rwanda between June 1 and November 31, 2016. Our primary outcomes included actual time to surgery (aTTS) in hours (defined as time from admission at ED to induction of anesthesia) and actual home to emergency department (ED) time (aHET) in days (defined as time from onset of symptoms to admission at ED). Our secondary outcome was the overall in-hospital mortality rate. RESULTS: During the study period, 148 emergency surgeries were performed. Most of the patients were male (80%), aged between 15 and 65 (69%), from outside Kigali (72%), and with insurance (80%). The most common diagnosis was abdominal trauma (24%), followed by peritonitis (20%), and intestinal obstruction (16%). The median aTTS was 7.8 h, and the median aHET was 2.43 days. Most patients (77%) experienced delays in timely surgery after admission to ED, and aTTS was 15.5 h for Fournier's gangrene, 10.8 h for abdominal trauma, 11.3 h for appendicitis, 10.5 h for intestinal obstructions, and 12.3 h for peritonitis. Likewise, most patients (52%) experienced delays in reaching the ED, especially those with appendicitis (15.2 days), peritonitis (8.5 days), testicular torsion (7.2 days), Fournier's gangrene (5 days), and intestinal obstruction (3.7 days). The case fatality rate by diagnosis was highest for polytrauma (100%) and peritonitis (60%); the overall in-hospital mortality rate was 23%. Some of the poor outcomes associated with in-hospital delay include reoperation and death. Factors to consider in triage for referral include age, diagnosis, and high risk of death. CONCLUSION: Our study found that the median aTTS was 7.8 h and most patients (77%) were delayed in having timely surgery after admission at ED. In addition, the median aHET was 2.5 days and most patients (52%) were delayed in reaching the ED. Improving processes to facilitate access and to perform timely emergency surgery through the referral system has a potential to decrease delay and improve outcomes.

Developing and implementing a novel mentorship model (4+ 1) for maternal, newborn and child health in Rwanda.

BACKGROUND: There are a number of factors that may contribute to high mortality and morbidity of women and newborns in low-income countries. These include a shortage of competent health care providers (HCP) and a lack of sufficient continuous professional development (CPD) opportunities. Strengthening the skills and building the capacity of HCP involved in the provision of maternal, newborn and child health (MNCH) is essential to ensure quality care for mothers, newborns and children. To address this challenge in Rwanda, mentorship of HCPs was identified as an approach that could help build capacity, improve the provision of care and accelerate the reduction in maternal and neonatal mortality and morbidity. In this paper, we describe the development and implementation of a novel mentorship model named Four plus One (4+ 1) for MNCH in Rwanda. METHODS: The mentorship model built on the basis of inter-professional collaboration (IPC) was developed in early 2017 through consultations with different key actors. The design phase included refresher courses in specific skills and training course on mentoring. Field visits were conducted in 10 hospitals from June 2017 to February 2020. Hospital management teams (MT) were involved in the development and implementation of this mentorship model to ensure ownership of the program. RESULTS: Upon completion of planned visits to each hospital, a total of 218 HCPs were involved in the process. Reports prepared by mentors upon each mentorship visit and compiled by Training Support and Access Model (TSAM) for MNCH'CPD team, highlighted the mothers and newborns who were saved by both mentors and mentees. Also, different logbooks of mentees showed how the capacity of staff was strengthened, thereby suggesting effectiveness of the model. Through different mentorship coordination meetings, the model was much appreciated by the MTs of hospitals, especially the IPC component of the model and confirmed the program 'effectiveness. CONCLUSION: The initiation of a mentorship model built on IPC together with the involvement of the leadership of the hospital may be the cause effect of reduction of specific mortality and improve MNCH in low resource settings even when there are a limited number of specialists in the health facilities.

Implementing the World Health Organization safe childbirth checklist in a district Hospital in Rwanda: a pre- and post-intervention study.

BACKGROUND: Worldwide maternal mortality remains high, with approximately 830 maternal deaths occurring each day. About 90% of these deaths occur in low-income countries. Evidenced-based essential birth practices administered during routine obstetrical care and childbirth are key to reducing maternal and neonatal deaths. The WHO Safe Childbirth Checklist (SCC) is a low-cost tool designed to ensure birth attendants perform 29 essential birth practices (EBP) at four critical periods in the birth continuum. This study aimed to evaluate compliance with EBP in Masaka District Hospital both before and after the implementation of the WHO-SCC. METHODS: This quality improvement project took place in the Masaka District Hospital in Rwanda. Observations of the 29 EBPs were done before and after WHO SCC implementation. The implementation process consisted of providing training in the use of the checklist to all clinical staff and posting SCC posters at different locations in the maternity unit. RESULTS: A total 391 birth events were observed pre-intervention and 389 post-intervention. The overall EBP compliance rate increased from 46% pre-intervention to 56% post-intervention (P = 0.005). Significant improvements were seen in 11 out of 29 EBPs. CONCLUSION: The implementation of the WHO SCC improved the overall EBP compliance rate in Masaka District Hospital. Determining the root cause of low compliance rate of some EBP may allow for more successful implementation of EBP interventions in the future. After further study, the SCC should be considered for scale up.