District Hospitals In Rwanda Research Articles

Maternal predictors of neonatal outcomes after emergency cesarean section: a retrospective study in three rural district hospitals in Rwanda

BackgroundIn sub-Saharan Africa, neonatal mortality post-cesarean delivery is higher than the global average. In this region, most emergency cesarean sections are performed at district hospitals. This study assesses maternal predictors for poor neonatal outcomes post-emergency cesarean delivery in three rural district hospitals in Rwanda.MethodsThis retrospective study includes a random sample of 441 neonates from Butaro, Kirehe and Rwinkwavu District Hospitals, born between 01 January and 31 December 2015. We described the demographic and clinical characteristics of the mothers of these neonates using frequencies and proportions. We assessed the association between maternal characteristics with poor neonatal outcomes, defined as death within 24 h or APGAR < 7 at 5 min after birth, using Fisher’s exact test. Factors significant at α = 0.20 significance level were considered for the multivariate logistic regression model, built using a backwards stepwise process. We stopped when all the factors were significant at the α = 0.05 level.ResultsFor all 441 neonates included in this study, 40 (9.0%) had poor outcomes. In the final model, three factors were significantly associated with poor neonatal outcomes. Neonates born to mothers who had four or more prior pregnancies were more likely to have poor outcomes (OR = 3.01, 95%CI:1.23,7.35, p = 0.015). Neonates whose mothers came from health centers with ambulance travel times of more than 30 min to the district hospital had greater odds of having poor outcomes (for 30–60 min: OR = 3.80, 95%CI:1.07,13.40, p = 0.012; for 60+ minutes: OR = 5.82, 95%CI:1.47,23.05, p = 0.012). Neonates whose mothers presented with very severe indications for cesarean section had twice odds of having a poor outcome (95% CI: 1.11,4.52, p = 0.023).ConclusionsLonger travel time to the district hospital was a leading predictor of poor neonatal outcomes post cesarean delivery. Improving referral systems, ambulance availability, number of equipped hospitals per district, and road networks may lessen travel delays for women in labor. Boosting the diagnostic capacity of labor conditions at the health center level through facilities and staff training can improve early identification of very severe indications for cesarean delivery for early referral and intervention.

Implementing the Emergency Triage, Assessment and Treatment plus admission care (ETAT+) clinical practice guidelines to improve quality of hospital care in Rwandan district hospitals: healthcare workers\u2019 perspectives on relevance and challenges

BackgroundAn emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.MethodsHCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.ResultsOne hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the “neonatal resuscitation and feeding” components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).ConclusionThis study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.

Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda

Background: Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.Objective: To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.Methods: Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.Results: Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6–90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03–6.43) and fluids (OR 2.69, 95% CI 1.2–6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21–25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57–8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15–6.41) monitored than those in rural hospitals.Conclusions: Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.

Pediatric emergency care capacity in a low-resource setting: An assessment of district hospitals in Rwanda.

BackgroundHealth system strengthening is crucial to improving infant and child health outcomes in low-resource countries. While the knowledge related to improving newborn and child survival has advanced remarkably over the past few decades, many healthcare systems in such settings remain unable to effectively deliver pediatric advance life support management. With the introduction of the Emergency Triage, Assessment and Treatment plus Admission care (ETAT+)–a locally adapted pediatric advanced life support management program–in Rwandan district hospitals, we undertook this study to assess the extent to which these hospitals are prepared to provide this pediatric advanced life support management. The results of the study will shed light on the resources and support that are currently available to implement ETAT+, which aims to improve care for severely ill infants and children.MethodsA cross-sectional survey was undertaken in eight district hospitals across Rwanda focusing on the availability of physical and human resources, as well as hospital services organizations to provide emergency triage, assessment and treatment plus admission care for severely ill infants and children.ResultsMany of essential resources deemed necessary for the provision of emergency care for severely ill infants and children were readily available (e.g. drugs and laboratory services). However, only 4/8 hospitals had BVM for newborns; while nebulizer and MDI were not available in 2/8 hospitals. Only 3/8 hospitals had F-75 and ReSoMal. Moreover, there was no adequate triage system across any of the hospitals evaluated. Further, guidelines for neonatal resuscitation and management of malaria were available in 5/8 and in 7/8 hospitals, respectively; while those for child resuscitation and management of sepsis, pneumonia, dehydration and severe malnutrition were available in less than half of the hospitals evaluated.ConclusionsOur assessment provides evidence to inform new strategies to enhance the capacity of Rwandan district hospitals to provide pediatric advanced life support management. Identifying key gaps in the health care system is required in order to facilitate the implementation and scale up of ETAT+ in Rwanda. These findings also highlight a need to establish an outreach/mentoring program, embedded within the ongoing ETAT+ program, to promote cross-hospital learning exchanges.

Health worker attrition at a rural district hospital in Rwanda: a need for improved placement and retention strategies

IntroductionThe shortage and maldistribution of health care workers in sub-Saharan Africa is a major concern for rural health facilities. Rural areas have 63% of sub-Saharan Africa population but only 37% of its doctors. Although attrition of health care workers is implicated in the human resources for health crisis in the rural settings, few studies report attrition rates and risk factors for attrition in rural district hospitals in sub-Saharan Africa.MethodsWe assessed attrition of health care workers at a Kirehe District Hospital in rural Rwanda. We included all hospital staff employed as of January 1, 2013 in this retrospective cohort study. We report the proportion of staff that left employment during 2013, and used a logistic regression to assess individual characteristics associated with attrition.ResultsOf the 142 staff employed at Kirehe District Hospital at the start of 2013, 31.7% (n=45) of all staff and 81.8% (n=9) of doctors left employment in 2013. Being a doctor (OR=10.0, 95% CI: 1.9-52.1, p=0.006) and having up to two years of experience at the hospital (OR=5.3, 95% CI: 1.3-21.7, p=0.022) were associated with attrition.ConclusionKirehe District Hospital experienced high attrition rates in 2013, particularly among doctors. Opportunities for further training through Rwanda’s Human Resources for Health program in 2013 and a two-year compulsory service program for doctors that is not linked to interventions for rural retention may have driven these patterns. Efforts to link these programs with rural placement and retention strategies are recommended.

Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

In developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients. This retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral. Of the 1,227 injured patients, 23.0% (n=282) were recommended for referral. Of these, 36.5% (n=103) had road traffic injuries and 53.6% (n=151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35years (odds ratio=2.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratio=16.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratio=10.25, 95% confidence interval: 2.70-38.82), and a duration ≥7days from admission to referral recommendation (odds ratio=4.80, 95% confidence interval: 1.38-16.63). Over 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.

Reducing post-cesarean wound infection at Muhororo Hospital by increasing hand hygiene practice

Purpose Post-cesarean wound infection (PCWI) is a common post-operative complication that can negatively affect patients and health systems. Poor hand hygiene practice of health care professionals is a common cause of PCWI. This case study aims to describe how strategic problem solving was used to introduce an alcohol-based hand rub in a district hospital in Rwanda to improve hand hygiene compliance among health care workers and reduce PCWI. Design/methodology/approach Pre- and post-intervention study design was used to address the poor hand hygiene compliance in the maternity unit. The hospital availed an alcohol-based hand rub and the team provided training on the importance of hand hygiene. A chart audit was conducted to assess the PCWI, and an observational study was used to assess hand hygiene compliance. Findings The intervention successfully increased hand hygiene compliance of health care workers from 38.2 to 89.7 per cent, p &lt; 0.001, and was associated with reduced hospital-acquired infection rates from 6.2 to 2.5 per cent, p = 0.083. Practical implications This case study describes the implementation process of a quality improvement project using the eight steps of strategic problem solving to introduce an alcohol-based hand rub in a district hospital in Rwanda. The intervention improved hand hygiene compliance among health care workers and reduced PCWI using available resources and effective leadership skills. Originality/value The results will inform hospitals with similar settings of steps to create an environment that enables hand hygiene practice, and in turn reduces PCWI, using available resources and strategic problem solving.

A quality improvement project to improve the accuracy in reporting hospital acquired infections in post cesarean section patients in a district hospital in Rwanda

Purpose Hospitals are responsible for protecting the well-being of their patients and staff. To do so, accurate information is needed for the hospital to make appropriate decisions and allocate resources efficiently. This study aims to describe the implementation process of a surveillance system to reduce hospital-acquired infection (HAI) reporting errors in the maternity unit of a district hospital in Rwanda. Design/methodology/approach The team adapted an evidence-based tool to identify and report HAI, provided training to staff and distributed reporting responsibilities equally between the maternity staff to improve accuracy in HAI reporting. Findings The intervention successfully reduced the reporting discrepancy of HAI from 6.5 to 1.9 per cent: p &lt; 0.05. Practical implications This case study described the implementation process of a surveillance system using strategic problem solving to reduce HAI reporting errors. The results can inform hospitals in similar settings of the steps to follow to implement a cost-neutral HAI surveillance system to reduce reporting errors. The accurate data will enable the hospital to take corrective measures to address HAI in the future. Originality/value The results will inform hospitals in similar settings of steps to follow to implement a cost-neutral HAI surveillance system using the SPS approach to reduce reporting errors.

Increasing patient medical record completion by assigning nurses to specific patients in maternity ward at Munini hospital

Purpose The purpose of this paper is to describe the quality improvement project to increase the medical record documentation completion rate in a district hospital in Rwanda. Despite the importance of medical records to support high quality and efficient care, incomplete documentation is common in many hospitals. Design/methodology/approach The pre- and post-intervention record completion rate in the maternity unit was assessed. Intervention included assigned nurse to specific patients, developed guideline, provided trainings and supervisions. Findings The documentation completion rate significantly increased from 25 per cent pre-intervention to 67 per cent post-intervention, p &lt; 0.001. The completeness of seven out of the ten elements of medical records also significantly increased. Practical implications The quality improvement project created a cost-effective intervention that successfully improved the documentation completion rate. Ongoing monitoring should be continued to learn sustainability. Originality/value The results are useful for hospitals with similar settings to improve completion of nursing documentation and increase nursing accountability on patient care.

Implementing a labor monitoring guideline and midwives responsibilities to increase the completion rate of partograph in Muhima Hospital, Rwanda

Purpose Complete health documentation during childbirth can reduce complications and improve maternal and foetal outcomes. One such document is the partograph which allows health workers to record and follow the labour progress. However, the completion rates of partograph remain low in some hospitals. This study describes the implementation of a quality improvement project to increase the completion rate of partograph in a district hospital in Rwanda. Design/methodology/approach The project team tackled the root cause of partograph incompletion by implementing a labour monitoring guideline, assigning patients and duties to midwives and by providing support and supervision. Findings The intervention successfully increased overall partograph completion rates from 11 to 61 per cent, p &lt; 0.001. This study also showed that completeness of the partograph was statistically associated with a decrease in foetal deaths and higher Apgar score with p &lt; 0.001 for both. Practical implications This study describes the establishment of a quality improvement project following the strategic problem solving approach to increase the completion rate of partograph documentation. The intervention was simple, data-driven and cost-neutral. The team achieved its objectives by integrating staff input, obtaining commitment from the multidisciplinary team and applying leadership skills. Originality/value The results are useful for hospitals in limited resources settings wishing to improve overall partograph completion and improve foetal and maternal outcomes during labour, in an efficient and cost-neutral way.

Quality improvement project to increase compliance of administration of corticosteroids and aminophylline in neonatal department of Mibilizi District Hospital

Purpose The purpose of this study is to describe how the hospital influenced the practice of corticosteroids and aminophylline administration by applying strategic problem solving. Under five child mortality is a challenge in Rwanda. Although it has been shown that administering corticosteroids and aminophylline can reduce the mortality of premature neonates, the use of these medications were low at Mibilizi District Hospital in Rwanda. Design/methodology/approach This project used a pre- and post-intervention study design, utilizing patient file audit to evaluate the impact of our intervention on the compliance of corticosteroids administration to pregnant mothers in premature labour and aminophylline to premature neonates, using the Strategic Problem Solving approach. Findings The intervention significantly increased the rate of giving corticosteroids to mothers at risk of premature delivery from 26 per cent to 60 per cent p-value = 0.009. The provision of aminophylline to premature neonates under 34 weeks of gestation significantly increased from 65 per cent to 100 per cent p-value = 0.002. Practical implications This study illustrates how a multidisciplinary team was able to use the eight steps of strategic problem solving to increase the administration rates of corticosteroids and aminophylline. The hospital should continue to support quality improvement efforts using strategic problem solving approach to prevent premature neonatal deaths and improve quality of care. Originality/value Findings from this study may be useful for hospitals in resource-challenged settings seeking to improve the administration of corticosteroids and aminophylline to prevent premature neonatal deaths.

Implementing wound dressing protocol to reduce post cesarean section surgical site infections in Mibilizi District Hospital, Rwanda

Purpose Caesarean section (CS) is one of the most common surgeries in the world. Although the procedure saves lives, it poses important risks such as post-caesarean surgical site infection (PCS-SSI). Basic patient care procedures can prevent PCS-SSI, however, they are not always followed. The purpose of this study is to describe how strategic problem solving (SPS) was used to implement a wound dressing protocol in a district hospital in Rwanda to reduce PCS-SSI rates. Design/methodology/approach To address variations in wound care practice, a new clinical protocol was developed and implemented by a quality improvement team which included clinicians. Training and supervision was also provided to the maternity team. Findings The intervention reduced PCS-SSI from 5.1 to 1.8 per cent. It also significantly improved the compliance to recommended wound dressing practices. Practical implications By applying SPS and effective leadership skills, the authors secured buy-in and support from stakeholders and introduced a wound management protocol in a district hospital of Rwanda. The intervention significantly improved wound management practice; however, long term follow-up will be necessary to sustain the improvements. Originality/value The results will inform hospitals in resource-limited settings of how to improve basic standards of care using SPS and leadership without additional cost to the hospital.

Establishing a tracking system in human resources department to improve the completeness of personnel files at a district hospital in Rwanda

Introduction: For decades, many low and mid income countries (LMIC) have invested significant effort to improve access to and quality of health care, with less attention paid to the non-clinical, administrative hospital management. Accordingly, a practical personnel filing system was designed and implemented to improve file management efficiency.Methods: Setting: The quality improvement project took place in a rural hospital in Rwanda. Design: A pre- and post-intervention study design to assess the effect of the intervention between January 2015 and February 2016. File auditing and time study were conducted. Intervention: A custom-made computer database to manage documents in a personnel file, standardized follow up process and policy were created and implemented. Measures: The pre- and post-intervention completeness of all personnel file and the average time to identify the missing items in a personnel file were measured to evaluate the effect of the project.Results: The completion rate of personnel files increased from 83% pre-intervention to 96% post-intervention. The average time to identify missing items significantly reduced from 6 minutes 30 seconds pre-intervention to 49.6 seconds (p &lt; .001).Conclusions: This project demonstrates that quality improvement principles can help address administrative issues in a resource-challenged setting. By utilizing available resources to implement an intervention that focused on creating an easy and efficient process, the personnel file completion rate has increased considerably and the time needed to identify missing items significantly decreased. The hospital should apply the same strategic problem solving methodology to conduct other quality improvement projects.

A quality improvement project to reduce intravenous catheter related infections in the neonatology unit of Kibogora hospital in Rwanda

In developing countries, intravenous (IV) catheter related infections (CRI) rate is generally high. Neonates are more susceptible to develop CRI. We examined the impact of a quality improvement project on IV CRI rates in the neonatal intensive care unit (NICU) of a district hospital in Rwanda. A pre- and post-intervention study was conducted from 2014 to 2016 to evaluate the IV CRI rate and nurses’ IV management technique. A written test was administered to evaluate their knowledge on the matter. The intervention had three components: First implementing an IV management policy. Secondly, training staff on the policy and finally, managers provided support and supervision during the change. We measured five indicators: (1) the IV CRI rate; (2) the percentage of nurses who tested 80% on IV management knowledge; (3) the percentage of IV devices changed following the World Health Organization (WHO) guideline; (4) IV management technique; and (5) the hospital length of stay (LOS). The IV CRI rate reduced from 32.1% to 14.5% (p &lt; .001). The hospital LOS reduced from 15.31 to 7.43 days (p &lt; .001). The compliance of changing IV following WHO guideline increased from 0% to 99% (p &lt; .001); proper IV management technique use increased from 43% to 96% (p &lt; .001); the mean rank of staff on IV management knowledge score significantly increased from 3.5 to 9.5 (p = .004). This project demonstrates that a quality improvement project can help address the IV CRI at very low cost in a resource-challenged setting.

IN PRINCIPLE YES, IN APPLICATION, NO; RWANDAN NURSES’ SUPPORT FOR INTERGRATION OF MENTAL HEALTH SERVICES

Mental ill-health contributes significantly to the global burden of disease as the fourth leading cause of global disability. To reduce this burden, by aiming at reduction of the treatment gap, the World Health Organisation recommended integration of mental health care into general health care structures, and deinstitutionalization coupled with community re-integration. Given the distribution of mental health professionals in Sub Sahara Africa the implementation of such integration is largely the work of nurses, specifically non mental health specialist nurses. Previous African studies report nurses difficulties with this integration; lack of preparation, knowledge, expertise, and time. Mental illness stigma is suggested to underscore a large portion of these difficulties. This quantitative study used a cross sectional survey approach to gather mental illness stigma related data from nurses (N=104, n=102) working within in a district hospital in Rwanda. A self-report questionnaire included person variables (age, gender, nursing experience, nursing qualification and category of nurse) and two scales; Level of Contact Scale (LOC), and Community Attitudes towards Mental Illness Scale - Swedish version (CAMI-S).Results support previous research regarding the type and extent of mental illness stereotypes, and mediating effects of familiarity. Significant associations between mental illness stereotypes and; younger and the less experienced nurses were also reported. However, the extent of contradiction within participant responses on the CAMI-S, across all demographics variables, suggests significant tension between nurses desire to subscribe to a nursing and national ideology of non-discrimination, a cherished value within the Rwandan context, and their fears associated with their stereotypical beliefs. In addition to the continued use of contact within health care worker training programs and clinical placements it is recommended that supportive interventions be implemented that are narrative in nature and facilitate the resolution of tension between ‘what I should believe’ and ‘what I do believe’.Key words: mental illness stereotypes, community based care, nurse, Rwanda

Report on the Treatment of Hodgkin Lymphoma With ABVD Chemotherapy at Two Rural District Hospitals in Rwanda

Abstract 34 Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high resource settings, there are few reports of HL treatment in low resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and preliminary outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy confirmed HL seen at Butaro and Rwinkwavu hospitals between June 2012 and August 2015. Data was extracted from clinical charts and analyzed using descriptive statistics. Results: 43 HL patients were seen at Butaro (n=38) and Rwinkwavu (n=5); 58% male, median age 17 (range 4-54). Five (12%) were HIV positive. Of 22 patients with biopsy specimens evaluated for EBV, 12 (55%) were positive, 9 (41%) negative, and one indeterminate. Most patients were staged with chest x-ray (79%); fewer had liver ultrasound (33%) or CT (9%). With that, Ann Arbor stages were I (28%), II (23%), III (21%), IV (21%), and undetermined (7%). Of 39 patients who started ABVD, 25 (64%) completed all 6 cycles. Median time to completion of the 24 week ABVD regimen was 26.1 weeks (IQR 25-27); 26 patients (67%) experienced at least one treatment delay. Dose reductions were rare. At the time of data extraction, 5 (12%) were still on treatment, 18 (43%) in remission, 2 (5%) alive with relapse, 15 (35%) deceased, and 2 (5%) lost to follow up. Conclusions: Here we demonstrate the feasibility of treating HL with standard chemotherapy in a low resource setting through international partnership. Our preliminary results suggest that a majority of patients who complete treatment may experience a clinically significant remission with this approach. Further data analysis will identify areas for improvement with the hope of increasing sustained remissions. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care.

BackgroundMost mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda.MethodsThis study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test.ResultsOf the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care.ConclusionSignificantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.

A Case Study and the Lessons Learned from In-House Alcohol Based Hand Sanitizer Production in a District Hospital in Rwanda

Health-care-associated infections (HCAIs) are a major global safety concern for patients, health- care professionals and public health particularly in developing countries where access to hand washing facilities is limited due to infrastructure. Alcohol-based hand sanitizer offers a viable alternative where water sources are unreliable or insufficient. However, in resource-limited settings, the introduction of alcohol-based hand sanitizer has been slow due to economic, manufacturing and procurement challenges compounded by the lack of evidence as to its acceptability in varying organizational cultures. This case study describes the process of producing, educating, distributing, scaling up and monitoring the impact of a quality improvement project to locally produce alcohol based hand sanitizer using the formula provided by the World Health Organization in a district hospital in Rwanda. During a 10-month implementation, hand sanitizer was made available to all departments of the hospital and all hospital staff received training on the proper use and ordering of the product. The overall hand hygiene compliance using any method significantly increased from 59% pre intervention to 67% post intervention (P < 0.001). Specifically, the use of hand sanitizer for hygiene significantly increased from 46% to 58% (P < 0.001). By producing hand sanitizer in-house, the hospital saved 71% when compared to purchasing commercial products. The use of hand sanitizer is not a replacement for running water in the hospital. However, with the lack of proper infrastructure, making hand sanitizer available is an acceptable alternative to improve the infection prevention and control standard. The production of hand sanitizer within a health care facility is cost effective and is feasible to integrate into existing operations. The team is working with the Rwandan Ministry of Health to introduce the program to all public hospitals as a national program.

Creating a Cleaner Informing System to Increase the Percentage of Clean Beds in the Post Cesarean Ward at Nyagatare Hospital, Rwanda

Hospital beds are one of the most frequently used non-invasive equipment in the clinical area and have a high risk of transmitting hospital acquired infections. However, they are usually not cleaned effectively. Accordingly, we conducted this quality improvement project to improve the bed cleaning process in a rural district hospital in Rwanda. A pre-post intervention study was conducted from in April 2015 to February 2016. The beds in the maternity unit were observed after patient was discharged. We implemented an alert system included using a signage system to help inform cleaners to clean the beds. Guidelines for the new system were created and trainings were provided. The intervention significantly increased the percentage of clean beds from 44% pre-intervention to 90% post-intervention (P < 0.001). 93% of staff followed the new labelling system. By focusing on system and process change, this quality improvement project successfully increased the percentage of clean beds without additional financial investment.

Remembering and Re-Experiencing Trauma during Genocide Commemorations: The Effect of Supportive-Expressive Group Therapy in a Selected District Hospital in Rwanda

From the 7th to the 13th April, Rwanda commemorates annually the genocide perpetrated against Tutsi in 1994. This second week of April is annually associated in Rwanda with an increase in traumatic crises whereby many people participating in commemorating ceremonies present with various symptoms, including re-experiencing traumatic events of the 1994 genocide. This paper presents and discusses the results of a study on a supportive-expressive group therapy model implemented by mental health nurses in a rural setting for people who experience repeated traumatic crises in the context of the genocide commemoration in Rwanda. Even though the supportiveexpressive group therapy was found ineffective for a series of variables studied (the number of crises presented in following commemorations, PTSD and depression symptoms), the results show that the intervention improved significantly the wellbeing of participants in terms of reduction of loneliness feelings and some negative emotions.Keywords: genocide, Rwanda, commemoration, traumatic crisis, supportive-expressive group therapy