Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country.

OBJECTIVE: To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting. METHODS: This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status. RESULTS: Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9-12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1-19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6-4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4-6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified. CONCLUSION: The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.

Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study.

INTRODUCTION: Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K). METHODS: At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016). DISCUSSION: In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.

Rwanda's Model Prehospital Emergency Care Service: A Two-year Review of Patient Demographics and Injury Patterns in Kigali.

Introduction Injury is responsible for nearly five million annual deaths worldwide, and nearly 90% of these deaths occur in low- and middle-income countries (LMICs). Reliable clinical data detailing the epidemiology of injury are necessary for improved care delivery, but they are lacking in these regions. METHODS: A retrospective review of the Service d'Aide Medicale Urgente (SAMU; Kigali, Rwanda) prehospital database for patients with traumatic injury-related conditions from December 2012 through November 2014 was conducted. Chi-squared analysis, binomial probability test, and student's t-test were used, where appropriate, to describe patient demographics, injury patterns, and temporal and geographic trends of injuries. RESULTS: In the two-year period, 3,357 patients were managed by SAMU for traumatic injuries. Males were 76.5% of the study population, and the median age of all injured patients was 29 years (IQR=23-35). The most common causes of injury were road traffic crashes (RTCs; 73.4%), stabbings/cuts (11.1%), and falls (9.4%), and the most common anatomic regions injured were the head (55.7%), lower (45.0%) extremities, and upper (27.0%) extremities. Almost one-fourth of injured patients suffered a fracture (24.9%). The most common mechanism of injury for adults was motorcycle-related RTCs (61.4%), whereas children were more commonly injured as pedestrians (59.8%). Centrally located sectors within Kigali represented common areas for RTCs. CONCLUSIONS: These data support the call for focused injury prevention strategies, some of which already are underway in Rwanda. Further research on care processes and clinical outcomes for injured patients may help identify avenues for improved care delivery. Enumah S , Scott JW , Maine R , Uwitonze E , Nyinawankusi JD , Riviello R , Byiringiro JC , Kabagema I , Jayaraman S . Rwanda's model prehospital emergency care service: a two-year review of patient demographics and injury patterns in Kigali. Prehosp Disaster Med. 2016;31(6):614-620.