Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study.

BACKGROUND: Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach. METHODS: This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency. DISCUSSION: Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

The BLOODSAFE program: Building the future of access to safe blood in Sub-Saharan Africa.

BACKGROUND: The supply of blood in many low- and middle-income nations in Sub-Saharan Africa (SSA) does not meet the patient care needs. Lack and delay of blood transfusion cause harm to patients and slow the rate of progress in other parts of the health system. Recognizing the power of implementation science, the BLOODSAFE Program was initiated which supports three SSA research study teams and one data coordinating center (DCC) with the goal to improve access to safe blood transfusion in SSA. STUDY DESIGN AND METHODS: The study team in Ghana is focusing on studying and decreasing iron deficiency in blood donors and evaluating social engagement of blood donors through different approaches. The study team in Kenya is building a "vein to vein" workflow model to elucidate and devise strategies to overcome barriers to blood donation and improve infrastructural components of blood product production and use. The Malawi team is studying the infectious disease ramifications of blood donation as well as blood donor retention strategies aimed at blood donors who commence their donation career in secondary schools. RESULTS AND DISCUSSION: Together the project teams and the DCC work as a consortium to support each other through a shared study protocol that will study donor motivations, outcomes, and adverse events across all three countries. The BLOODSAFE Program has the potential to lead to generalizable improvement approaches for increasing access to safe blood in SSA as well as mentoring and building the research capacity and careers of many investigators.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange.

BACKGROUND: As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya. METHODS: Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed. RESULTS: Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program. CONCLUSION: As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions.

There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.

Implementing the Trauma Evaluation and Management (TEAM) Course in Kenya.

BACKGROUND: Trauma training provides crucial knowledge and skills for health-care providers in low- and middle-income countries (LMICs). Although such training has been adapted for physicians and emergency personnel in LMICs, few courses have been offered for medical students. The Trauma Evaluation and Management (TEAM) course, developed by the American College of Surgeons, provides a valuable framework for providing this content to medical students in an LMIC-context. MATERIALS AND METHODS: We implemented the TEAM course at a single medical school in rural Kenya, for final-year medical students, utilizing the multimodal instruction and reference materials provided by the American College of Surgeons. We administered precourse and postcourse assessments, adapted the content for particular low-resource considerations, expanded the course to 2 d, and utilized a multidisciplinary and multinational group of surgical expert instructors. RESULTS: The entire final-year medical school class participated, and all completed pretesting and posttesting (100%, n = 61). Posttesting revealed significant improvement (P < 0.001), demonstrating successful knowledge acquisition, with the greatest improvements among the poorest performing decile on the pretest (P < 0.05). On narrative course feedback (100% completion, n = 61), participants appreciated instructors' interactive teaching style and the course's practical demonstrations, while requesting more time allotment for trauma training. CONCLUSIONS: We describe the feasibility of implementing TEAM training for final-year medical students in Kenya and demonstrate the course's effectiveness in this context as shown by knowledge acquisition. We plan for additional study to assess interval knowledge and skill retention. With refinement based on these results, we plan to repeat and expand trauma-education initiatives for medical students in LMICs.

Perception of medical professionalism among the surgical community in the University of Nairobi: a mixed method study.

BACKGROUND: Professionalism defines the relationship between colleagues, patients and the society as a whole. Furthermore, being a social construct, professionalism is sophisticated to be regarded simply as a single concept across different cultural contexts. This study sought to explore how professionalism is conceptualized by the clinicians, students and patients in a teaching hospital in Kenya. METHODS: A sequential mixed methods study was conducted among clinicians, students and patients at Kenyatta National Hospital on the surgical wards from March 1(st)-December 31(st), 2014. The first phase of the study involved focus group discussions (FGDs) of between 10-12 persons and individual in-depth interviews of senior faculty and patients. Grounded theory method was used for collecting perceptions of participants on professionalism. These views were then coded using Atlas 5.2, allowing the development of a questionnaire that provided the survey tool for the second phase of the study. For the questionnaire, response options utilized a 4-point Likert scale with a range from "strongly agree" to "strongly disagree". Factor analysis was used to analyse the responses to the survey. Internal reliability was determined by Cronbach's α. RESULTS: Sixteen FGDs and 18 in-depth interviews were held with 204 clinicians, students and patients. A further 188 participants completed the questionnaire. Respect was the most frequently mentioned or picked component of professionalism during the interview and survey respectively, with 74.5 % of participants reporting "strongly agree". Factor analysis showed that 3 factors accounted for the majority of the variance in the items analysed; respect in practice, excellence in service and concern for the patient. The Cronbach's α for this analysis was 0.927. CONCLUSION: The study cohort predominantly conceptualizes professionalism as relating to respect between colleagues and toward patients. Respect, being a cultural norm, should form part of the core curriculum of professionalism in order to be relevant for the Kenyan context.

Operative Exposure of a Surgical Trainee at a Tertiary Hospital in Kenya.

Background. Psychomotor domain training requires repetitive exposure in order to develop proficiency in skills. This depends on many training factors in any training institution. Objective. This study sought to look at the operative exposure of surgical trainees in a tertiary hospital in a developing country. Design and Setting. This was a six-month retrospective study performed in one surgical firm at Kenyatta National Hospital. Patients and Methods. The files of all patients admitted to the unit at that time were retrieved. The demographics, diagnosis at admission, need for surgery, and cadre of operating surgeon among others were recorded. Scientific Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results. The study cohort was 402 patients of the 757 patients admitted in the study period. The average age was 36.7 years, a female to male ratio of 1 : 2.5. The majority (69.7%) of patients required surgery. Trauma was the most common reason for admission (44.5%). Year 2 residents received the most clinical exposure. Consultant was available in only 34.5% of the cases. Conclusion. The junior residents performed the vast majority of procedures with an unsatisfactory amount of supervision from the senior residents and faculty.

An evidence-based review: distracted driver.

BACKGROUND: Cell phone use and texting are prevalent within society and have thus pervaded the driving population. This technology is a growing concern within the confines of distracted driving, as all diversions from attention to the road have been shown to increase the risk of crashes. Adolescent, inexperienced drivers, who have the greatest prevalence of texting while driving, are at a particularly higher risk of crashes because of distraction. METHODS: Members of the Injury Control Violence Prevention Committee of the Eastern Association for the Surgery of Trauma performed a PubMed search of articles related to distracted driving and cell phone use as a distractor of driving between 2000 and 2013. RESULTS: A total of 19 articles were found to merit inclusion as evidence in the evidence-based review. These articles provided evidence regarding the relationship between distracted driving and crashes, cell phone use contributing to automobile accidents, and/or the relationship between driver experience and automobile accidents. (Adjust methods/results sections to the number of articles that correctly corresponds to the number of references, as well as the methodology for reference inclusion.) CONCLUSION: Based on the evidence reviewed, we can recommend the following. All drivers should minimize all in-vehicle distractions while on the road. All drivers should not text or use any touch messaging system (including the use of social media sites such as Facebook and Twitter) while driving. Younger, inexperienced drivers should especially not use cell phones, texting, or any touch messaging system while driving because they pose an increased risk for death and injury caused by distractions while driving.

Complicated malaria and a covert ruptured spleen: a case report.

Spontaneous splenic rupture in complicated malaria is an uncommon cause of hemoperitoneum in the tropics. The exact incidence of splenic rupture is unknown, largely due to under-reporting, but has been estimated at ∼2%. Its pathophysiology is linked to the formation of a subcapsular hematoma. Upon rupture, patients present with features of shock and peritonitis and in most cases (95%), computed tomography (CT) scan detects the splenic injury. Patients should be managed conservatively with splenectomy reserved for patients with shock and hemoperitoneum due to risk of post-splenectomy sepsis. We report the case of a 38-year-old man with severe malaria who presented with fever, chills and abdominal pains. A CT scan abdomen failed to reveal splenic parenchymal injury or any splenic extravasation of contrast. Conservative management was unsuccessful. Exploratory laparatomy confirmed the spleen as the site of bleeding necessitating a splenectomy.

Early trauma induced coagulopathy (ETIC): prevalence across the injury spectrum.

INTRODUCTION: Newer studies have hypothesised about a coagulopathy that occurs early after trauma, early trauma induced coagulopathy, ETIC, and is defined by an elevated admission prothrombin time (PT). Also, referred to by some authors as acute traumatic coagulopathy, it has been most often studied in cohorts of severely injured or hypotensive patients. However, we wanted to prospectively investigate ETIC in a large all-comers cohort to confirm its prevalence across the entire spectrum of injury, to evaluate its risk pattern and to determine a possible relationship to reduced survival. METHODS: We conducted a prospective cohort study at a Level I trauma centre from July 15, 2008 to November 15, 2009. Demographics, injury mechanism, time from injury and to hospital arrival, fluid and blood administration and vital signs were collected at hospital arrival and to the time of first blood sample collection for all patients admitted for 24h or longer. Our primary outcome was the incidence of mortality by the 28th hospital day, referred to as 28 day in-hospital mortality. RESULTS: 701 patients were included in the final study cohort. There was 75.3% male, 25.7% penetrating, with a mean age of 39 years. The overall mortality was 7.3%. ETIC occurred in 114 patients (16.3%) and was found to be independently associated with death (odds of death (per 0.10s increase in PT): 1.10, p=0.001). ETIC patients, as a group, were more severely injured, had more hypotension and head injury and used more crystalloid and blood products than non-ETIC patients. However, even mildly injured patients, who had an ISS<16, normal RTS score, and no fluid resuscitation, had an ETIC prevalence of 11.7% (11/94). CONCLUSIONS: ETIC is an early, primary post-injury coagulopathy that occurs in 16.3% of admitted trauma patients. It is associated with an increase in mortality, even when controlling for crystalloids, vital signs, injury severity and head injury. It can also be found in approximately 11% of mildly injured patients (patients without physiological derangement or blood product administration). Therefore, further elucidation of ETIC is strategic to impacting trauma patient outcome.

Interventional studies for preventing surgical site infections in sub-Saharan Africa - A systematic review.

BACKGROUND: There is a great need for safe surgical services in sub-Saharan Africa, but a major difficulty of performing surgery in this region is the high risk of post-operative surgical site infection (SSI). METHODS: We aimed to systematically review which interventions had been tested in sub-Saharan Africa to reduce the risk of SSI and to synthesize their findings. We searched Medline, Embase and Global Health databases for studies published between 1995 and 2010 without language restrictions and extracted data from full-text articles. FINDINGS: We identified 24 relevant articles originating from nine countries in sub-Saharan Africa. The methodological quality of these publications was diverse, with inconsistency in definitions used for SSI, period and method of post-operative follow-up and classification of wound contamination. Although it was difficult to synthesise information between studies, there was consistent evidence that use of single-dose pre-operative antibiotic prophylaxis could reduce, sometimes dramatically, the risk of SSI. Several studies indicated that alcohol-based handrubs could provide a low-cost alternative to traditional surgical hand-washing methods. Other studies investigated the use of drains and variants of surgical technique. There were no African studies found relating to several other promising SSI prevention strategies, including use of checklists and SSI surveillance. CONCLUSIONS: There is extremely limited research from sub-Saharan Africa on interventions to curb the occurrence of SSI. Although some of the existing studies are weak, several high-quality studies have been published in recent years. Standard methodological approaches to this subject are needed.

Adrenocorticotropic hormone and cortisol response to corticotropin releasing hormone in the critically ill-a novel assessment of the hypothalamic-pituitary-adrenal axis.

BACKGROUND: The pathophysiology of adrenal insufficiency, common in surgical intensive care units, has not been fully elucidated. METHODS: Patients at risk (age > 55 years, in the surgical intensive care unit >1 week, baseline cortisol < 20 µg/dL) were enrolled. After measuring cortisol and adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH) was administered. ACTH and cortisol were measured over 120 minutes. Short and long cosyntropin stimulation tests determined adrenal function. Area under the curve (AUC) and mixed linear models were used to compare cortisol and ACTH responses. Patients were grouped according to survival and response to stimulation testing. Chi-square and t tests were performed, and P values < .05 were considered statistically significant. RESULTS: Six of 25 patients responded poorly to cosyntropin, and 5 died compared with 3 after a normal response (P < .01). ACTH (AUC) and ACTH peak were increased in nonsurvivors after CRH administration. Cortisol peak and AUC were not different. CONCLUSIONS: ACTH responsiveness was increased in nonsurvivors and may predict mortality.

Alcohol-related injury visits: do we know the true prevalence in U.S. trauma centres?

INTRODUCTION: Alcohol consumption is a significant risk factor for injuries. Further, level I trauma centres are mandated to screen and provide a brief intervention for identified problem drinkers. However, a valid population-based estimate of the magnitude of the problem is unknown. Therefore, the goal of this study is to evaluate the extent to which the present literature provides a valid estimate of the prevalence of alcohol-related visits to U.S. trauma centres. METHODS: A Medline search for all articles from 1966 to 2007 that might provide prevalence estimates of alcohol-related visits to U.S. trauma centres yielded 836 articles in English language journals. This review included only papers whose main or secondary goal was to estimate the prevalence of positive blood alcohol concentration (BAC) or acute intoxication. Both a crude aggregate estimate and sample size adjusted estimate were calculated from the included papers and the coverage and comparability of methods were evaluated. RESULTS: Of the 15 studies that met inclusion criteria, incidence estimates of alcohol-related visits ranged from 26.2% to 62.5% and yielded an aggregate, weighted estimate of 32.5%. Target population, capture rate, and threshold for a positive screening result varied considerably across studies. No study provided a comprehensive estimate, i.e., of all trauma patients hospitalised, treated and released, or who died. CONCLUSIONS: Although the incidence of alcohol-related visits to U.S. trauma centres appears very high perhaps higher than any other medical setting, the validity of our aggregate estimate is threatened by crucial methodological considerations. The lack of a methodologically valid prevalence estimate hinders efforts to devise appropriate policies for trauma centres and across medical settings.

Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review.

BACKGROUND: The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience. FINDINGS: Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained. DISCUSSION: This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.

Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation factor depletion.

BACKGROUND: Trauma patients present with a coagulopathy, termed early trauma-induced coagulopathy (ETIC), that is associated with increased mortality. This study investigated hemostatic changes responsible for ETIC. METHODS: Case-control study of trauma patients with and without ETIC, defined as prolonged prothrombin time (PT), was performed from prospective cohort of consecutive trauma patients who presented to Level I trauma center. Univariate and multivariate analyses were performed. RESULTS: The case-control study group (n = 91) was 80% male, with mean age of 37 years, 17% penetrating trauma and 7% mortality rate. Patients with ETIC demonstrated decreased common and extrinsic pathway factor activities (factors V and VII) and decreased inhibition of the coagulation cascade (antithrombin and protein C activities) when compared with the matched control patients without ETIC. Both cohorts had evidence of increased thrombin and fibrin generation (prothrombin fragment 1.2 levels, thrombin-antithrombin complexes, and soluble fibrin monomer), increased fibrinolysis (d-dimer levels), and increased inhibition of fibrinolysis (plasminogen activator inhibitor-1 activity) above normal reference values. Patients with versus without ETIC had increased mortality and received increased amount of blood products. CONCLUSION: ETIC following injury is associated with decreased factor activities without significant differences in thrombin and fibrin generation, suggesting that despite these perturbations in the coagulation cascade, patients displayed a balanced hemostatic response to injury. The lower factor activities are likely secondary to increased hemodilution and coagulation factor depletion. Thus, decreasing the amount of crystalloid infused in the early phases following trauma and administration of coagulation factors may prevent the development.

Medical student surgery elective in rural Haiti: a novel approach to satisfying clerkship requirements while providing surgical care to an underserved population.

BACKGROUND: The addition of global health programs to medical school training results in graduates with enhanced clinical skills and increased sensitivity to cost issues. Funding from U.S. medical schools has been unable to meet student demand, and therefore it is often a critical limiting factor to the lack of development of these programs. We describe an alternative approach for global health surgical training for medical students. METHODS: Emory University medical students and faculty, in collaboration with Project Medishare for Haiti, planned, raised funds, and executed a successful short-term surgical camp to supplement available surgical services in rural Haiti. Learning objectives that satisfied Emory University School of Medicine surgery clerkship requirements were crafted, and third-year students received medical school credit for the trip. RESULTS: In the absence of house staff and placed in an under-resourced, foreign clinical environment, the surgical elective described here succeeded in meeting learning objectives for a typical third-year surgical clerkship. Objectives were met through a determined effort to ensure that home institution requirements were aligned properly with learning activities while students were abroad and through a close collaboration between medical students, faculty members, and the administration. CONCLUSIONS: Emory University's international surgery elective for medical students demonstrates that opportunities for supervised, independent student-learning and global health service can be integrated into a traditional surgical clerkship. These opportunities can be organized to meet the requirements and expectations for third-year surgery clerkships at other medical colleges. This work also identifies how such trips can be planned and executed in a manner that does not burden strained academic budgets with further demands on resources.

Evaluation of fundamental critical care course in Kenya: knowledge, attitude, and practice.

BACKGROUND: Critical care training for medical personnel is crucial for the survival of the highest acuity patients. The Fundamental Critical Care Course (FCCS), a critical care course developed by the Society of Critical Care Medicine, permits course adaption and, thus, has potential for global dissemination. The FCCS course was provided in two Kenyan hospitals after minimal adaption. Participant knowledge and confidence gain as well as FCCS applicability to an African context were evaluated. METHODS: Questionnaires and a multiple-choice test were administered to assess knowledge, attitude, and self-reported confidence or self-efficacy. For applicability, the pre-course questionnaire assessed participant expectations and existing levels of confidence/knowledge in the care of the critically ill patient. Post-course, the participant evaluated the overall quality of the course, lectures, and skill stations along with context applicability questions. RESULTS: There were 100 participants, 45 doctors, 45 nurses, and 10 clinical officers. There was a 22.7% gain in the mean test score (P < 0.0001) after the course, with 98% of participants showing improvement. Confidence to perform new skills post-course, or self-efficacy, was demonstrated by a median of 4 or greater on a Likert scale of 5 (most confident) in 10 of 12 clinical scenarios and in 11 of 14 new procedures. There was a consistency between areas reported as needed expertise, and participant evaluation of similar lecture and skill station's quality and appropriateness. The most common areas reported were mechanical ventilation, patient monitoring, and their related procedures. CONCLUSIONS: The FCCS course met participant's expectations and was reported as applicable for the Kenyan context with minimal adaption. Post-course, knowledge improved and confidence increased for implementation of new skills in clinical care situations. We confirmed the effectiveness and relevancy of the FCCS course for other resource-constrained health care settings.