193 Impact of Implementation of Emergency Medicine Training on Emergency Department Mortality in Kigali, Rwanda: An Interrupted Time-Series Quasi-Experimental Design

Abstract

Although emergency medicine (EM) training programs have recently been introduced in low- and middle-income countries (LMICs), no data exists on their effects on patient-centered outcomes in resource-limited settings. This study evaluated the impact of EM training on emergency department (ED) mortality among patients treated at the University Teaching Hospital of Kigali (UTH-K) ED. The study was conducted at UTH-K, the primary public referral hospital in Rwanda. An EM post-graduate diploma program was begun at UTH-K in October 2013 and full EM residency training program was begun in September 2015. Prior to initiation of these training programs, care was provided exclusively by general practice physicians (GPs); since initiation, ED care has been provided through mutually exclusive shifts allocated between GPs and EM resident (EMR) trainees who have oversight by board certified emergency physicians. All patients presenting to the ED during the nine-month period prior to initiation of the EM training (Jan.-Sept., 2013) and nine-months following the start of the EM residency program (Sept. 2015-June 2016) were eligible for inclusion. Study personnel abstracted data from a random sample of hospital records using a structured collection instrument. Prevalence and risk differences (RD) of all cause ED mortality were compared for cases treated before and after EM training initiation and based on provider type (GPs or EMRs). Secular trends were assessed and magnitudes of effects were quantified using odds ratios (OR) with 95% confidence intervals (CI). Multivariate models were adjusted a priori for age, type and severity of illness. From the 35,491 encounters during the study period, 2,580 cases were randomly sampled. There were 1,480 cases prior to training initiation and 1,100 after. The median age was 32 years (inter-quartile range (IQR): 22, 49) with a male predominance (59.9%). Medical patients comprised 54.0% of cases and injuries account for 46.0%. Median ED length of stay (LOS) was 1 day (IQR: 0, 3). The majority of cases were admitted (55.4%). Compared to the pre-implementation period, post implementation cases were more likely to be admitted (p<0.001). Pre-implementation mortality prevalence was 6.8% (95% CI: 5.4, 8.2%); post-implementation prevalence was 1.2% (95% CI: 0.5, 1.9%). In multivariate regression, as compared to ED cases treated prior to the initiation of the EM training program, those treated after were less likely to suffer ED mortality (aOR=0.14, 95% CI: 0.07, 0.30; p<0.001). In assessment by provider type, ED mortality among cases treated by GPs was 6.6% (95% CI: 5.5, 7.6%) and 1.3% (95% CI: 1.6, 2.4%) for those treated by EMRs. In regression analysis, compared to cases treated by GPs those treated by EM trainees were significantly less likely to experience ED mortality (aOR=0.08, 95% CI: 0.01, 0.55; p=0.011). No differences in secular trends in mortality were identified based on shift type either prior to (RD: 0.5%, 95% CI: -0.4, 4.6%; p=0.79) or after training initiation (RD: 0.9%, 95% CI: -0.8, 2.6%; p=0.35). ED mortality was significantly reduced with implementation of EM training in the studied population in Rwanda. Although limited by design aspects, these results demonstrate the benefit on an objective patient-centered outcome of EM training in a LMIC, and supports further research and investment in EM training in resource-limited settings.