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.

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.

Developing and implementing a global emergency medicine course: Lessons learned from Rwanda.

BACKGROUND: There is a growing demand by medical trainees for meaningful, short-term global emergency medicine (EM) experiences. EM programs in high-income countries (HICs) have forged opportunities for their trainees to access this experience in low-and middle-income countries (LMICs). However, few programs in LMICs have created and managed such courses. As more LMICs establish EM programs, these settings are ideal for developing courses beneficial for all participants. We describe our experience of creating and implementing a short-term global EM course in Rwanda. OBJECTIVES: The objectives of this study were to (1) provide EM trainees from HICs with an opportunity to observe global clinical practice and to learn from local experts, (2) provide EM trainees from an LMIC with an opportunity to share their expert knowledge and skills with HIC trainees, (3) create a sustainable model for a short-term global EM course in an LMIC context. METHODS: A global EM curriculum and course were developed in Rwanda, entitled EM in the Tropics Emergency Medicine in the Tropics (EMIT). The following topics were covered: EM systems development, public health, trauma/triage, pediatrics, disaster management, and tropical EM. A one-and two-week course program was created and implemented. RESULTS: EMIT participants rotated through pediatric and adult EDs, Intensive Care Unit, trauma surgery, internal medicine, emergency medical services, and ultrasound training. Activities included bedside teaching, case presentations, ultrasound practice, group lectures, simulation and skills workshops, and a rotation to a district hospital. A total of 11 participants attended: six for both weeks and five for 1 week. The course raised $5000 USD, which was dedicated in full to sponsoring local EM residents to attend international conferences. DISCUSSION: The EMIT course in Rwanda achieved its objectives of teaching and learning between all participants. Benefits of this in-person experience for both visiting and local participants are clear in clinical, intercultural, and professional ways. CONCLUSION: Our experience of developing and implementing EMIT in Rwanda demonstrates that EM programs in LMICs can provide short-term global EM courses that are not only beneficial to all participants, but also logistically and financially sustainable.

Attitudes, beliefs, and practices toward end-of-life care among physicians in sub-Saharan Africa.

Introduction: as the opportunity to receive life-sustaining treatments expands in sub-Saharan Africa (SSA), so do potential ethical dilemmas. Little is known regarding the attitudes, beliefs, and practices of physicians in SSA regarding end-of-life care ethics. Methods: we used validated survey items addressing physician end-of-life care views and added SSA-context specific items. We identified a convenience sample using the authors' existing African professional contacts and snowball recruitment. Participants were invited via email to an anonymous online survey. Results: we contacted 78 physicians who practice critical care in Africa, and 68% (n=53) completed the survey. Of those, 66% were male, 55% were aged 36-45, 75% were Christian. They were from Kenya (30%), Zambia (28%), Rwanda (25%), Botswana (11%), and other countries (6%). Most (75%) agreed that competent patients can refuse even life-saving care. Only 32% agreed that their hospital had clear policies regarding withdrawing and withholding care, 11% agreed that their country had legal precedent for end-of-life care, and 43% believed that doctors could face legal or financial consequences for allowing patients to die by forgoing treatment. Pain control at the end of life, even if it may hasten death, was supported by 83%. However, 75% felt that clinicians undertreat pain due to fear of hastening death. Conclusion: participants strongly supported patient autonomy and end-of-life pain control but expressed concern that inadequate policy and legal frameworks exist to guide care and that pain is undertreated. Humane and actionable end-of-life care frameworks are needed to guide decisions in SSA.

Impact of ultrasound on management for dyspnea presentations in a Rwandan emergency department.

BACKGROUND: The complexity of diagnosis for critically ill dyspnea presentations in the emergency department remains a challenge. Accurate and rapid recognition of associated life-threatening conditions is paramount for timely treatment. Point-of-care ultrasound (POCUS) has been shown to impact the diagnosis of dyspnea presentations in resource-rich settings, and may be of greater diagnostic benefit in resource-limited settings. METHODS: We prospectively enrolled a convenience sample of 100 patients presenting with dyspnea in the Emergency Department at University Teaching Hospital of Kigali (UTH-K) in Rwanda. After a traditional history and physical exam, the primary treating team listed their 3 main diagnoses and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). Multi-organ ultrasound scans performed by a separate physician sonographer assessed the heart, lungs, inferior vena cava, and evaluated for lower extremity deep vein thrombosis or features of disseminated tuberculosis. The sonographer reviewed the findings with the treating team, who then listed 3 diagnoses post-ultrasound and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). The hospital diagnosis at discharge was used as the standard in determining the accuracy of the pre- and post-ultrasound diagnoses. RESULTS: Of the 99 patients included in analysis, 57.6% (n = 57) were male, with a mean age of 45 years. Most of them had high-level acuity (54.5%), the dyspnea was of acute onset (45.5%) and they came from district hospitals (50.5%). The most frequent discharge diagnoses were acute decompensated heart failure (ADHF) (26.3%) and pneumonia (21.2%). Ultrasound changed the leading diagnosis in 66% of cases. The diagnostic accuracy for ADHF increased from 53.8 to 100% (p = 0.0004), from 38 to 85.7% for pneumonia (p = 0.0015), from 14.2 to 85.7% for extrapulmonary tuberculosis (p = 0.0075), respectively, pre and post-ultrasound. The overall physician diagnostic accuracy increased from 34.7 to 88.8% pre and post- ultrasound. The clinician confidence in the leading diagnosis changed from a mean of 3.5 to a mean of 4.7 (Likert scale 0-5) (p < 0.001). CONCLUSIONS: In dyspneic patients presenting to this Emergency Department, ultrasound frequently changed the leading diagnosis, significantly increased clinicians' confidence in the leading diagnoses, and improved diagnostic accuracy.

Building and Sustaining Partnerships in Health Workforce and Research Capacity in Rwanda.

Rwanda's ambitious Human Resources for Health (HRH) program comes to an end this year, having made great strides towards achieving its aim to create a large, diverse and competent health workforce, and will have graduated over 4,500 healthcare professionals since its inception in 2012. The HRH program was based on strong collaborative relationships between Rwandan and United States academic institutions and faculty and now stands poised to enter a new phase focused on sustaining the many gains achieved. Fostering career development of new Rwandan faculty and building health research capacity are key components to sustaining the mutually beneficial partnerships that have been forged over the past seven years, with the goal of creating strong Rwandan health researchers that can advance knowledge of best practices for patient care and public health, appropriate to the Rwandan context and other resource-limited settings.

The "Just Right" Amount of Oxygen. Improving Oxygen Use in a Rwandan Emergency Department.

Rationale: Despite oxygen's classification as an essential medication by the World Health Organization, it is inconsistently available in many resource-constrained settings. Hypoxemia is associated with increased mortality, and mounting evidence suggests that hyperoxia may also be associated with adverse outcomes.Objectives: To determine if overuse of oxygen for some patients in a Rwandan tertiary care hospital emergency department might coexist with oxygen shortages and underuse of oxygen for other patients, and whether an educational intervention coupled with provision of pulse oximeters could improve the distribution of limited oxygen resources.Methods: We screened all patients in the adult emergency department (ED) of the University Teaching Hospital of Kigali for hypoxemia and receipt of oxygen therapy for 5 weeks. After completing baseline data collection, we provided pulse oximeters and conducted a didactic training with pre- and posttests on oxygen titration, with a chosen target oxygen saturation (SpO2) of 90% to 95%. Four and 12 weeks after the intervention, we evaluated all patients in the ED again for SpO2 and receipt of oxygen therapy for 4 weeks each period. We also recorded ED oxygen use and availability of reserve oxygen for the hospital during the three study periods.Results: During all data collection periods, 214 of 1,765 (12.1%) unique patients screened were hypoxemic. The proportion of patient-days with appropriately titrated oxygen therapy (SpO2, 90-95%) increased from 18.7% at baseline to 38.5% and 42.0% at 4 and 12 weeks postintervention (P < 0.001). On a multiple-choice examination testing knowledge of appropriate oxygen titration, clinicians' scores improved from average 60% (interquartile range [IQR], 40-80%) correct to 80% (IQR, 60-80%) correct immediately after the educational intervention (P < 0.001). Oxygen use in the ED decreased from a median of 32.0 (IQR, 28.0-35.0) tanks per day to 25.5 (IQR, 24.0-29.0) and 16.0 (IQR, 12.5-21.0) tanks per day at Weeks 4 and 12, respectively (P < 0.001), and the median daily number of tanks in reserve for the hospital appeared to increase, although this did not reach statistical significance (30.0 [IQR, 9.0-46.0], 86.5 [IQR, 74.0-92.0], and 75.5 [IQR, 8.5-88.5], respectively; P = 0.07).Conclusions: Among patients in a Rwandan adult ED, 12.1% of patients were hypoxemic and 81.3% of patient-days were either under- or overtreated with oxygen during baseline data collection on the basis of our defined target of SpO2 90% to 95%. Follow-up results at 4 and 12 weeks postintervention demonstrated sustained improvement in oxygen titration and likely increased availability of oxygen resources.

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.