Challenges Locating the Scene of Emergency: A Qualitative Study of the EMS System in Rwanda.

BACKGROUND: Timely prehospital emergency care significantly improves health outcomes. One substantial challenge delaying prehospital emergency care is in locating the patient requiring emergency services. The goal of this study was to describe challenges emergency medical services (EMS) teams in Rwanda face locating emergencies, and explore potential opportunities for improvement. METHODS: Between August 2021 and April 2022, we conducted 13 in-depth interviews with three stakeholder groups representing the EMS response system in Rwanda: ambulance dispatchers, ambulance field staff, and policymakers. Semi-structured interview guides covered three domains: 1) the process of locating an emergency, including challenges faced; 2) how challenges affect prehospital care; and 3) what opportunities exist for improvement. Interviews lasted approximately 60 min, and were audio recorded and transcribed. Applied thematic analysis was used to identify themes across the three domains. NVivo (version 12) was used to code and organize data. RESULTS: The current process of locating a patient experiencing a medical emergency in Kigali is hampered by a lack of adequate technology, a reliance on local knowledge of both the caller and response team to locate the emergency, and the necessity of multiple calls to share location details between parties (caller, dispatch, ambulance). Three themes emerged related to how challenges affect prehospital care: increased response interval, variability in response interval based on both the caller's and dispatcher's individual knowledge of the area, and inefficient communication between the caller, dispatch, and ambulance. Three themes emerged related to opportunities for processes and tools to improve the location of emergencies: technology to geolocate an emergency accurately and improve the response interval, improvements in communication to allow for real-time information sharing, and better location data from the public. CONCLUSION: This study has identified challenges faced by the EMS system in Rwanda in locating emergencies and identified opportunities for intervention. Timely EMS response is essential for optimal clinical outcomes. As EMS systems develop and expand in low-resource settings, there is an urgent need to implement locally relevant solutions to improve the timely locating of emergencies.

Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda.

Introduction: Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. Methods: In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants' perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. Results: Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. Conclusion: Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

Introduction: Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. Methods: In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants' perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. Results: Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. Conclusion: Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

Epidemiology of Patients with Head Injury at a Tertiary Hospital in Rwanda.

INTRODUCTION: Traumatic injuries disproportionately affect populations in low and middle-income countries (LMIC) where head injuries predominate. The Rwandan Ministry of Health (MOH) has dramatically improved access to emergency services by rebuilding its health infrastructure. The MOH has strengthened the nation's acute emergency response by renovating emergency departments (ED), developing the field of emergency medicine as a specialty, and establishing a prehospital care service: Service d'Aide Medicale Urgente (SAMU). Despite the prevalence of traumatic injury in LMIC and the evolving emergency service in Rwanda, data regarding head trauma epidemiology is lacking. METHODS: We conducted this retrospective cohort study at the University Teaching Hospital of Kigali (UTH-K) and used a linked prehospital database to investigate the demographics, mechanism, and degree of acute medical interventions amongst prehospital patients with head injury. RESULTS: Of the 2,426 patients transported by SAMU during the study period, 1,669 were found to have traumatic injuries. Data from 945 prehospital patients were accrued, with 534 (56.5%) of these patients diagnosed with a head injury. The median age was 30 years, with most patients being male (80.3%). Motor vehicle collisions accounted for almost 78% of all head injuries. One in six head injuries were due to a pedestrian struck by a vehicle. Emergency department interventions included intubations (6.7%), intravenous fluids (2.4%), and oxygen administration (4.9%). Alcohol use was not evaluated or could not be confirmed in 81.3% of head injury cases. The median length of stay (LOS) in the ED was two days (interquartile range: 1,3). A total of 184 patients were admitted, with 13% requiring craniotomies; their median in-hospital care duration was 13 days. CONCLUSION: In this cohort of Rwandan trauma patients, head injury was most prevalent amongst males and pedestrians. Alcohol use was not evaluated in the majority of patients. These traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of head injury, may be beneficial in the Rwandan setting.

Building Trauma and EMS Systems Capacity in Rwanda: Lessons and Recommendations.

Background: Surgical capacity building has gained substantial momentum. However, care at the hospital level depends on improved access to emergency services. There is no established model for facilitating trauma and EMS system capacity in LMIC settings. This manuscript describes our model for multi-disciplinary collaboration to advance trauma and EMS capacity in Rwanda, along with our lessons and recommendations. Methods: After high-level meetings at the Ministry of Health in Rwanda (MOH), in 2016, a capacity building plan focusing on improved clinical services, quality improvement/research and leadership capacity across prehospital and emergency settings. The main themes for the collaborative model included for empowerment of staff, improving clinical service delivery, and investing in systems and infrastructure. Funding was sought and incorporated into the Sector Wide Approaches to Planning process at the Ministry of Health of Rwanda. Findings: A shared mental model was created through a fully funded immersion program for Rwandese leaders from emergency medicine, nursing, prehospital care, and injury policy. Prehospital care delivery was standardized within Kigali through a train-the-trainers program with four new context-appropriate short courses in trauma, medical, obstetric/neonatal, and pediatric emergencies and expanded across the country to reach >600 staff at district and provincial hospitals. Forty-two protocols and checklists were implemented to standardize prehospital care across specialties. The WHO Trauma Registry was instituted across four major referral centers in the country capturing over 5,000 injured patients. Long-term research capacity development included Masters' Degree support for 11 staff. Conclusions and Recommendations: This collaboration was highly productive in empowering staff and leadership, standardizing clinical service delivery in EMS, and investing in systems and infrastructure. This can be a useful model for trauma and EMS system capacity development in other LMICs.

Prehospital emergency obstetric and neonatal care train-the-trainers program in Rwanda.

OBJECTIVE: To improve maternal mortality rates, our collaboration developed and implemented a context-specific, prehospital Emergency Obstetrics and Neonatal Course (EONC) and train-the-trainers program in Rwanda. METHODS: Two cohorts of staff participated in the program-the SAMU emergency medical service and staff from district hospitals. A 2-day course was developed, consisting of skills stations, simulations, and didactics. A 50-question assessment was administered to both cohorts before and after the courses. Student's t test and matched paired t tests were used to evaluate the assessments through retrospective analysis of the data. RESULTS: EONC1 median scores were 60% versus 92% (pre vs post), using matched-pair analysis of 20 participants. EONC2 median scores were 52% versus 96% (pre vs post), using matched-pair analysis of participants. A one-way analysis of variance mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores (F(1)  = 8.35, P = 0.0059). CONCLUSION: Optimal prehospital management of obstetric emergencies is essential to prevent needless mortality and morbidity. This study demonstrated that a context-appropriate prehospital obstetric and neonatal training program could be effectively developed and implemented for the SAMU team in Kigali, Rwanda.

Musculoskeletal Injuries and Outcomes Pre- and Post- Emergency Medicine Training Program.

INTRODUCTION: Musculoskeletal injuries (MSI) comprise a large portion of the trauma burden in low- and middle-income countries (LMIC). Rwanda recently launched its first emergency medicine training program (EMTP) at the University Teaching Hospital-Kigali (UTH-K), which may help to treat such injuries; yet no current epidemiological data is available on MSI in Rwanda. METHODS: We conducted this pre-post study during two data collection periods at the UTH-K from November 2012 to July 2016. Data collection for MSI is limited and thus is specific to fractures. We included all patients with open, closed, or mixed fractures, hereafter referred to as MSI. Gathered information included demographics and outcomes including death, traumatic complications, and length of hospital stay, before and after the implementation of the EMTP. RESULTS: We collected data from 3609 patients. Of those records, 691 patients were treated for fractures, and 674 of them had sufficient EMTP data measured for inclusion in the analysis of results (279 from pre-EMTP and 375 from post-EMTP). Patient demographics demonstrate that a majority of MSI cases are male (71.6% male vs 28.4% female) and young (64.3% below 35 years of age). Among mechanisms of injury, major causes included road traffic accidents (48.1%), falls (34.2%), and assault (6.0%). There was also an observed association between EMTP and trends of the three primary outcomes: a reduction of death in the emergency department (ED) from those with MSI by 89.9%, from 2.51% to 0.25% (p = 0.0077); a reduction in traumatic complications for MSI patients by 71.7%, from 3.58% to 1.01% (p = 0.0211); and a reduction in duration of stay in the ED among those with MSI by 52.7% or 2.81 days on average, from 5.33 to 2.52 days (p = 0.0437). CONCLUSION: This study reveals the current epidemiology of MSI morbidity and mortality for a major Rwandan teaching hospital and the potential impacts of EM training implementation among those with MSI. Residency training programs such as EMTP appear capable of reducing mortality, complications, and ED length of stay among those with MSI caused by fractures. Such findings underscore the efficacy and importance of investments in educating the next generation of health professionals to combat prevalent MSI within their communities.

Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis.

INTRODUCTION: Injury is a major cause of premature death and disability in East Africa, and high-quality pre-hospital care is essential for optimal trauma outcomes. The Rwandan pre-hospital emergency care service (SAMU) uses an electronic database to evaluate and optimize pre-hospital care through a continuous quality improvement programme (CQIP), beginning March 2014. MATERIALS AND METHODS: The SAMU database was used to assess pre-hospital quality metrics including supplementary oxygen for hypoxia (O2), intravenous fluids for hypotension (IVF), cervical collar placement for head injuries (c-collar), and either splinting (splint) or administration of pain medications (pain) for long bone fractures. Targets of >90% were set for each metric and daily team meetings and monthly feedback sessions were implemented to address opportunities for improvement. These five pre-hospital quality metrics were assessed monthly before and after implementation of the CQIP. Met and unmet needs for O2, IVF, and c-collar were combined into a summative monthly SAMU Trauma Quality Scores (STQ score). An interrupted time series linear regression model compared the STQ score during 14 months before the CQIP implementation to the first 14 months after. RESULTS: During the 29-month study period 3,822 patients met study criteria. 1,028 patients needed one or more of the five studied interventions during the study period. All five endpoints had a significant increase between the pre-CQI and post-CQI periods (p<0.05 for all), and all five achieved a post-CQI average of at least 90% completion. The monthly composite STQ scores ranged from 76.5 to 97.9 pre-CQI, but tightened to 86.1-98.7 during the post-CQI period. Interrupted time series analysis of the STQ score showed that CQI programme led to both an immediate improvement of +6.1% (p=0.017) and sustained monthly improvements in care delivery-improving at a rate of 0.7% per month (p=0.028). CONCLUSION: The SAMU experience demonstrates the utility of a responsive, data-driven quality improvement programme to yield significant immediate and sustained improvements in pre-hospital care for trauma in Rwanda. This programme may be used as an example for additional efforts engaging frontline staff with real-time data feedback in order to rapidly translate data collection efforts into improved care for the injured in a resource-limited setting.

Development of a trauma and emergency database in Kigali, Rwanda.

INTRODUCTION: Injuries account for 10% of the global burden of disease, resulting in approximately 5.8 million deaths annually. Trauma registries are an important tool in the development of a trauma system; however, limited resources in low- and middle-income countries (LMIC) make the development of high-quality trauma registries challenging. We describe the development of a LMIC trauma registry based on a robust retrospective chart review, which included data derived from prehospital, emergency centre and inpatient records. METHODS: This paper outlines our methods for identifying and locating patients and their medical records using pragmatic and locally appropriate record linkage techniques. A prehospital database was queried to identify patients transported to University Teaching Hospital - Kigali, Rwanda from December 2012 through February 2015. Demographic information was recorded and used to create a five-factor identification index, which was then used to search OpenClinic GA, an online open source hospital information system. The medical record number and archive number obtained from OpenClinic GA were then used to locate the physical medical record for data extraction. RESULTS: A total of 1668 trauma patients were transported during the study period. 66.7% were successfully linked to their medical record numbers and archive codes. 94% of these patients were successfully linked to their medical record numbers and archive codes were linked by four or five of the five pre-set identifiers. 945 charts were successfully located and extracted for inclusion in the trauma registry. Record linkage and chart extraction took approximately 1256 h. CONCLUSION: The process of record linkage and chart extraction was a resource-intensive process; however, our unique methodology resulted in a high linkage rate. This study suggests that it is feasible to create a retrospective trauma registry in LMICs using pragmatic and locally appropriate record linkage techniques.

INTRODUCTION: Les blessures sont responsables de 10% de la charge mondiale de morbidité, résultant sur environ 5,8 millions de décès par an. Les registres des traumatismes constituent un outil important pour le développement d'un système sur les traumatismes; cependant, les ressources limitées qui caractérisent les pays à revenu faible et intermédiaire font que le développement de registres des traumatismes de qualité est difficile. Nous décrivons le développement d'un registre des traumatismes dans les pays à revenu faible et intermédiaire à partir d'un examen rétrospectif approfondi des dossiers incluant des données tirées des registres pré-hospitaliers, des services d'urgence et des patients hospitalisés. MÉTHODES: Cet article décrit les méthodes dont nous disposons pour identifier et localiser les patients et leurs dossiers médicaux en utilisant des techniques de couplage de dossiers pragmatiques et localement appropriées. Une base de données pré-hospitalières a été interrogée afin d'identifier les patients transportés à l'Hôpital universitaire de Kigali, au Rwanda, de décembre 2012 à février 2015. Les informations démographiques ont été enregistrées et utilisées afin de créer un indice d'identification à cinq facteurs, utilisé ensuite pour mener une recherche dans OpenClinic GA, un système d'information hospitalière en open source accessible en ligne. Les numéros de dossiers médicaux et les codes d'archives obtenu par OpenClinic GA ont été ensuite utilisés pour localiser le dossier médical physique afin d'en extraire les données. RÉSULTATS: Au total, 1668 patients ayant souffert de traumatisme ont été transportés au cours de la période à l'étude. 66,7% ont pu être couplés à leur numéro de dossier médical et code d'archive. 94% de ces patients ont pu être couplés à 4 ou 5 des cinq identifiants préétablis. 945 fichiers ont pu être localisés et extraits pour être intégrés au registre des traumatismes. Le couplage des dossiers et l'extraction des fiches ont nécessité environ 1 256 heures. CONCLUSION: Le processus de couplage de dossiers et d'extraction des fiches a nécessité des ressources considérables; cependant, notre méthodologie unique a résulté sur un taux de couplage élevé. Cette étude suggère qu'il est possible de créer un registre des traumatismes rétrospectif dans les pays à revenu faible et intermédiaire en utilisant des techniques de couplage de dossiers localement appropriées.

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.