Hospital In Rwanda Research Articles

Resuscitation team training in Rwanda: A mixed method study exploring the combination of the VAST course with Advanced Cardiac Life Support training

IntroductionThe influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda. MethodsParticipants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention. ResultsForty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p = <0.001; [137.3 (108.9) sec] versus [51.3 (37.9)], p = <0.001; and [218.5 (105.8) sec] versus [110.8 (87.1) sec], p = <0.001; respectively. These improvements were maintained following the Vital Anaesthesia Simulation Training Course, and at 3-month retention testing. Qualitative analysis highlighted five key themes: ability to initiate cardiopulmonary resuscitation; team coordination for task allocation; empowerment; desire for training and mentorship; and advocacy for system improvement. ConclusionA modified 2-day Advanced Cardiac Life Support course improved resuscitation time indicators with retention 3-months later. Combining the Vital Anaesthesia Simulation Training Course and Advanced Cardiac Life Support led to better team coordination, empowerment to act, and advocacy for system improvement. This pairing of courses has promise for improving Advanced Cardiac Life Support skills amongst healthcare workers in low-resource settings.ClinicalTrials.gov Identifier: NCT05278884.

Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda

To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country. Retrospective review of the clinical and laboratory components of patients undergoing invitro fertilization (IVF) treatment in Rwanda from 2018 to2020. Academic tertiary referral hospital in Rwanda. Patients seeking infertility services beyond the primary gynecological options. The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature. Assessment of functional clinical and laboratory infertility services and costs. A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively. Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.

Establishment of Haematological Reference Values for Healthy Individuals Attending Ruhengeri Referral Hospital in Rwanda

Background: The Laboratory investigations are very important for reaching to definitive diagnosis of diseases orientation and thus enabling optimal patient management based on informed diagnoses. Decision, and these are very difficult to obtain in the absence of reference values. In many cases, laboratory diagnosis such as haematological analyses are dependent on pre-defined locally established reference values. Objective of the study: The objective of this study was to describe ranges of haematological reference values for healthy individuals attending Ruhengeri referral Hospital in Rwanda Methodology: The cross sectional study was carried out in Northern Province at Ruhengeri referral hospital from July 2018 to September 2018. Participants were 252 healthy individuals aged less than one year to 68 years. From each participant, 4mL of blood samples were collected using K3 EDTA containers, and then analysed by Sysmex XS-500i automated haematology analyser. Results: Haemoglobin levels varied with age and sex. The level decreased with the increasing age, and males had high haemoglobin level than females (15.69g/dL versus 14.46g/dL). Minimum mean values of haematological parameters for study participants were slightly on the high side with narrow confidence intervals compared to the Manufactured Sysmex values. Conclusion: The findings may be used to define normal haematological values for Rwandan population and help physicians to better define haematological abnormalities in patients.

Assessment of Biochemical Parameters of Graft Survivors Post Renal Transplantation at King Faisal Hospital in Rwanda

Background: Chronic kidney disease (CKD) remains a public health concern of 21st century. Each year, over million people die from CKD resulting from the lack of proper diagnosis and treatment of this terrible disease of the urinary system. Non-communicable diseases (NCDs) cause roughly 60% of all deaths worldwide. There is insufficient data in Rwanda for the management of kidney diseases and other NCDs for all health facilities. Renal substitution therapy appears to be the best solution for long–suffering patients with end-stage renal illness who want to survive. The study’s purpose was to find out the serum creatinine and blood urea nitrogen (BUN) concentrations among kidney transplanted patients at King Faisal Hospital of Rwanda, and to show the consequences linked with the transplantation of kidney. Methods: This was a retrospective study carried from November 2018 to December 2019. The data were collected from medical records at King Faisal Referral Hospital, and analysed with SPSS version 22. Results: BUN and serum creatinine concentrations ranged from 77.4 to 93.5% and 67.8 to 87.1%, respectively. BUN levels that were abnormally high ranged from 3.2 to 19.4%, while creatinine levels that were abnormally high ranged from 6.5 to 29.0%. BUN and creatinine levels that were abnormally low, ranged from 0.0 to 6.5 and 3.2 to 9.7%, respectively. Diabetes mellitus affected 19.35% of the study population, hypertension affected 35.48%, and antibodymediated rejection affected 6.45%. Conclusion: The slight change in biochemical parameters may be a problem after kidney transplantation. There should be a monitoring of biochemical parameters tests to prevent the post kidney transplantation complications.

Assessment of knowledge and practices of hand hygiene among health workers in Rwanda

BackgroundHand hygiene (HH) has proven to be the leading measure to prevent the cross-transmission of microorganisms. However, HH compliance among healthcare workers has been very low in Rwanda, with average compliance of<40%. There was no nationwide data related to HH compliance in Rwanda except for a few studies in different institutions on quality improvement. The research aimed to assess the hand hygiene knowledge level and compliance among the health care providers at Kirehe District Hospital. MethodsA cross-sectional study was conducted among 29 healthcare workers (20 nurses/midwives and 9 doctors) working at the maternity unit at Kirehe District Hospital in Rwanda. Knowledge was assessed using the WHO HH questionnaire. ResultsThe overall knowledge score was 77.5%, and 44% of participants had moderate HH knowledge. Gloves were 98% available and accessible to health professionals. The hand rub was available in 52%, mostly used by doctors who carried it in their pockets (40.6). The availability of soap and water was 45% and 29%, respectively. A binomial test was done to see if there was any factor that was associated with HH knowledge; it was found that there was no statistically significant association between knowledge and demographics. ConclusionThe findings of this study showed that most healthcare workers had good knowledge of HH. Healthcare workers were observed putting on gloves without washing their hands between patients during rounds. The HH infrastructure was poorly located, with limited supplies, and there were no hand-washing facilities in some rooms.

Antimicrobial Resistance Profile of Bacteria Causing Pediatric Infections at the University Teaching Hospital in Rwanda.

Bacterial infections pose a global threat, especially in the pediatric population. Antimicrobials that are used to treat such infections continuously show reduced efficacy, and empirical therapy is a major treatment option in Rwanda. This study aimed to determine the resistance rate of commonly used antibiotics in pediatric patients. The study was conducted from June 1, 2018 to May 30, 2019, and microbiological samples were collected from 712 children with suspected bacterial infections. Antimicrobial sensitivity testing was performed on 177 positive cultures (24%) that were considered for data analysis. The findings show that the major bacterial isolates were Klebsiella pneumoniae (n = 50, 28.2%), Escherichia coli (n = 47, 26.5%), and Staphylococcus aureus (n = 38, 21.4%). In general, the greatest antibiotic resistance rate was observed in ampicillin (n = 125, 86.2%), amoxicillin-clavulanic acid (n = 84, 82.4%), amoxicillin (n = 64, 79%), cefadroxil (n = 83, 69.2%), tetracycline (n = 72, 59.7%), ceftazidime (n = 42, 55.3%), and cefuroxime (n = 14, 53.8%). More specifically, Klebsiella pneumoniae was 100% resistant to amoxicillin-clavulanic acid, cefuroxime, trimethoprim-sulfamethoxazole, ceftazidime, erythromycin, and clindamycin. Staphylococcus aureus was 86.7% resistant to ampicillin, and Escherichia coli was 91.7% resistant to tetracycline, 90.6% resistant to ampicillin, 83.3% resistant to amoxicillin-clavulanic acid, 79.3% resistant to cefadroxil, and 78.6% resistant to ceftazidime. Moreover, Klebsiella pneumoniae from blood and urine was 96.8% and 100% sensitive, respectively, to meropenem. Staphylococcus aureus from blood was 100% sensitive to vancomycin, whereas Escherichia coli from urine was sensitive to clindamycin (100%), nitrofurantoin (80.6%), and ciprofloxacin (72.7%). In conclusion, our findings show a high resistance rate to commonly used antibiotics, which suggests precaution in empirical therapy and continued surveillance of antimicrobial resistance.

Group psychoeducation for persons with bipolar disorder in Rwanda: a study protocol for a randomized controlled trial

BackgroundThe efficacy of psychoeducation as an add-on treatment to pharmacotherapy is well documented in treating symptoms and in relapse prevention for persons with bipolar disorder in western countries. Yet, no studies on psychosocial interventions for persons with bipolar disorder have been conducted in a low-income country in Africa.AimTo develop a bipolar group psychoeducation program contextualized to the Rwandese setting, and determine its effect on symptom severity, medical adherence, and internalized stigma.MethodsA culturally adapted guide manual was developed by local mental health professionals, including nurses, psychologists, and medical doctors. In-depth interviews with participants were held prior to and will be held following the intervention to address the cultural aspect of living with bipolar disease and the impact of the program. A two-armed randomized controlled trial has been set up at the tertiary mental health hospitals in Rwanda, with an intervention and a waiting list arm. A sample size of at least 50 in each arm was calculated as a requirement. The study’s primary outcome measure will be the difference in relapse rate measured on the Young Mania Rating Scale and Hamilton Depression Scale-17. Differences in mean change on scales for medical adherence and internalized stigma will be secondary outcomes. Data will be analyzed according to the intention-to-treat principle. Participants will be assessed subsequently at baseline, at the end of the intervention period, and three months and 12 months post-intervention.DiscussionThis study will be one of the first intervention trials on bipolar disorder in a low-income country. If proven successful in reducing morbidity and increasing the quality of life in persons with bipolar disorder, it is anticipated that the psychoeducation program can be implemented at the district and community level and act as inspiration for other low-resource settings.Trial registrationClinicalTrials.gov NCT04671225. Registered on November 2020.

Assessment of formats and completeness of paper-based referral letters among urban hospitals in Rwanda: a retrospective baseline study

BackgroundPatient referral is a process in which a healthcare provider decides to seek assistance due to the limitations of available skills, resources and services offered locally. Paper-based referrals predominantly used in low-income countries hardly follow any procedure. This causes a major gap in communication, coordination, and continuity of care between primary and specialized levels, leading to poor access, delay, duplication and unnecessary costs. The goal of this study is to assess the formats and completeness of existing paper-based referral letters in order to improve health information exchange, coordination, and continuity of care.MethodsA retrospective exploratory research was conducted in eight public and three private healthcare facilities in the city of Kigali from May to October 2021. A purposive sampling method was used to select hospitals and referral letters from patients’ files. A data capture sheet was designed according to the contents of the referral letters and the resulting responses were analyzed descriptively.ResultsIn public hospitals, five types of updated referral letters were available, in total agreement with World Health Organization (WHO) standards of which two (neonatal transfer form and patient monitoring transfer form) were not used. There was also one old format that was used by most hospitals and another format designed and used by a district hospital (DH) separately. Three formats were designed and used by private hospitals (PH) individually. A total of 2,304 referral letters were perused and the results show that “external transfer” forms were completed at 58.8%; “antenatal, delivery, and postnatal external transfer” forms at 47.5%; “internal transfer” forms at 46.6%; “Referral/counter referral” forms at 46.0%; district hospital referrals (DH2) at 73.4%. Referrals by private hospitals (PH1, PH2 and PH3) were completed at 97.7%, 70.7%, and 0.0% respectively. The major completeness deficit was observed in counter referral information for all hospitals.ConclusionWe observed inconsistencies in the format of the available referral letters used by public hospitals, moreover some of them were incompatible with WHO standards. Additionally, there were deficits in the completeness of all types of paper-based referral letters in use. There is a need for standardization and to disseminate the national patient referral guideline in public hospitals with emphasis on referral feedback, referral registry, triage, archiving and a need for regular training in all organizations.

Investigating the Association Between a Risk-Directed Prophylaxis Protocol and Postoperative Nausea and Vomiting: Validation in a Low-Income Setting.

The efficacy of postoperative nausea and vomiting (PONV) prevention protocols in low-income countries is not well known. Different surgical procedures, available medications, and co-occurring diseases imply that existing protocols may need validation in these settings. We assessed the association of a risk-directed PONV prevention protocol on the incidence of PONV and short-term surgical outcomes in a teaching hospital in Rwanda. We compared the incidence of PONV during the first 48 hours postoperatively before (April 1, 2019-June 30, 2019; preintervention) and immediately after (July 1, 2019-September 30, 2019; postintervention) implementing an Apfel score-based PONV prevention strategy in 116 adult patients undergoing elective open abdominal surgery at Kigali University Teaching Hospital in Rwanda. Secondary outcomes included time to first oral intake, hospital length of stay, and rate of wound dehiscence. Interrupted time series analyses were performed to assess the associated temporal slopes of the outcome before and immediately after implementation of the risk-directed PONV prevention protocol. Compared to just before the intervention, there was no change in the odds of PONV at the beginning of the postintervention period (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.05-1.01). There was a decreasing trend in the odds of nausea (OR, 0.60; 95% CI, 0.36-0.97) per month. However, there was no difference in the incidence of nausea immediately after implementation of the protocol (OR, 0.96; 95% CI, 0.25-3.72) or in the slope between preintervention and postintervention periods (OR, 1.48; 95% CI, 0.60-3.65). In contrast, there was no change in the odds of vomiting during the preintervention period (OR, 1.01; 95% CI, 0.61-1.67) per month. The odds of vomiting decreased at the beginning of the postintervention period compared to just before (OR, 0.10; 95% CI, 0.02-0.47; P = .004). Finally, there was a significant decrease in the average time to first oral intake (estimated 14 hours less; 95% CI, -25 to -3) when the protocol was first implemented, after adjusting for confounders; however, there was no difference in the slope of the average time to first oral intake between the 2 periods ( P = .44). A risk-directed PONV prophylaxis protocol was associated with reduced vomiting and time to first oral intake after implementation. There was no substantial difference in the slopes of vomiting incidence and time to first oral intake before and after implementation.

A collaboration to improve perioperative acute pain care at the University Teaching Hospital of Butare, Rwanda

&#x0D; &#x0D; &#x0D; BACKGROUND: A perioperative acute pain care program integrating standardized assessment and treatment forms into pain care was developed and implemented at an urban hospital in Rwanda through a collaboration between Rwandan and Canadian experts. This study evaluated the perioperative acute pain care program using a quality improvement lens.&#x0D; METHODS: Using the Model for Improvement: Plan, Do, Study, Act (PDSA) cycle, a mixed methods evaluation was performed. Over one year, 519 randomized patient chart audits were conducted and analyzed through control charts. Through purposeful sampling, focus groups comprised ofsurgeons and nurses (N=34) involved in pain care in surgery, obstetrics, and anesthesiology were performed and analyzed via thematic coding.&#x0D; RESULTS: The average attempted form completion rate across all forms varied monthly between 56-93% (mean=79%; median=81%). Across all forms, both the mean and median total number of errors per form were 12.5. Enablers of form use included improved pain care for patients and feelings of professional satisfaction. Program implementation was challenged by resource constraints, form integration, and health care provider training.&#x0D; CONCLUSION: Future quality improvement collaborations should identify and address improved pain care while working with local experts to ensure PDSA cycles are continuous, and evidence based.&#x0D; &#x0D; &#x0D;

Nutritional intake in acute care surgery patients in Kigali, Rwanda- A single institution descriptive analysis

&#x0D; &#x0D; &#x0D; INTRODUCTION: Nutrition is essential for health and healing, especially in the perioperative period. However, little is known about the nutritional intake of hospitalized patients in low and middle-income countries.This paper aimed to characterize the composition and quantity of food in acute care surgery patients at a tertiary referral hospital in Rwanda.&#x0D; METHODS: Acute care surgery patients were queried about nutritional intake during hospitalization from May 21, 2018, to June 3, 2018, for 100 patient days. Calorie and protein intake were estimated and compared to standards for an average Rwandan adult.RESULTS: Median daily calorie intake was 1472 kcal/day (Interquartile range (IQR): 662, 2116). The median daily protein intake was 45.99 g (IQR: 24.38, 70.22). Assuming a calorie need of 25 kcal/kg/day and a protein need of 1g/kg/day, this is 98.1% of the estimated daily calorie needs and 76.7% of estimated daily protein needs. Estimating higher energy needs for a surgical patient, the daily intake is 70.0-81.9% of calorie needs and 51.1-63.9% of protein needs.&#x0D; CONCLUSION: Overall, the calorie and protein intake for the average Rwandan acute care surgery patient were low compared to the needs of a 60 kg surgical patient. More education and accessibility to high-quality foods are needed to ensure adequate nutrition in the postoperative period to optimize clinical outcomes.&#x0D; &#x0D; &#x0D;

Burnout Syndrome Among Anesthesia Providers Working in Public Hospitals in Rwanda: A Cross-Sectional Survey.

Many studies address anesthesia provider burnout in high-income countries; however, there is a paucity of data on burnout for anesthesia providers in low-income countries (LICs). Our objectives were (1) to evaluate the prevalence of burnout among anesthesia providers in Rwandan hospitals and (2) to determine factors associated with burnout among anesthesia providers in Rwandan hospitals. A questionnaire was sent to selected Rwandan anesthesia providers working in public hospitals. The questionnaire assessed burnout using the Maslach Burnout Inventory Human Services Survey, a validated 22-item survey used to measure burnout among health professionals. Sociodemographic and work-related factors found to be associated with burnout were also assessed using logistic regression in a Bayesian framework to estimate odds ratios (OR) and associated credible intervals (CrIs). Surveys were distributed to 137 Rwandan anesthesia providers; 99 (72.3%) were returned. Sixty-six (67%) respondents were nonphysician anesthesia providers. Burnout was present in 26 of 99 (26.3%) participants (95% confidence interval [CI], 17.9-36.1). When considering weakly informative priors, we found a 99% probability that not having the right team (OR, 5.36%; 95 CrI, 1.34-23.53) and the frequency of seeing patients with negative outcomes such as death or permanent disability (OR, 9.62; 95% CrI, 2.48-42.84) were associated with burnout. In a cross-sectional survey of anesthesia providers in Rwanda, more than a quarter of respondents met the criteria for burnout. Lacking the right team and seeing negative outcomes were associated with higher burnout rate. These identified factors should be addressed to prevent the negative consequences of burnout, such as poor patient outcomes.

Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda

IntroductionIn low-income and middle-income countries, there is a high demand for surgical care, although many individuals lack access due to its affordability, availability, and accessibility. Costs are an important metric in healthcare and can influence healthcare access and outcomes. The aim of this study was to determine the financial impact of infections in acute care surgery patients and factors associated with inability to pay the hospital bill at a Rwandan referral hospital. Materials and methodsThis was a prospective observational study of acute care surgery patients at a tertiary referral hospital in Rwanda with infections. Data were collected on demographics, clinical features, hospital charges, and expenses. Factors associated with inability to pay the hospital bill were analyzed using Chi-squared and Wilcoxon rank sum tests. ResultsOver 14 mo, 191 acute care surgery patients with infections were enrolled. Most (n = 174, 91%) patients had health insurance. Median total hospital charges were 414.24 United States Dollars (interquartile range [IQR]: 268.20, 797.48) and median patient charges were 41.53 USD (IQR: 17.15, 103.09). At discharge, 53 (28%) patients were unable to pay their hospital bill. On a univariate analysis actors associated with inability to pay the bill included transportation via ambulance, occupation as a farmer, diagnosis, complications, surgical site infection, and length of hospital stay. On a multivariable analysis, intestinal obstruction (adjusted odds ratio 4.56, 95% confidence interval 1.16, 17.95, P value 0.030) and length of hospital stay more than 7 d (adjusted odds ratio 2.95, 95% confidence interval 1.04, 8.34, P value 0.042) were associated with inability to pay the final hospital bill. ConclusionsAlthough there is broad availability of health insurance in Rwanda, hospital charges and other expenses remain a financial burden for many patients seeking surgical care. Further innovative efforts are needed to mitigate expenses and minimize financial risk.

A mixed-method study exploring experiences, perceptions, and acceptability of using a safe delivery mHealth application in two district hospitals in Rwanda

BackgroundInnovative use of mobile health (mHealth) technology in timely management of childbirth complications is a promising strategy, but its evidence base is limited. The Safe Delivery mHealth Application (SDA) is one of the recent mhealth applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC). This paper describes, the health providers’ experiences, perceptions, and acceptability of using the SDA, as well as the perceptions of key stakeholders.MethodsA mixed-methods approach was utilized. Quantitative methods consisted of a self-reported acceptability survey, administered to 54 nurses and midwives, including questions on their usage and perceptions of the SDA. Descriptive statistics were employed to analyze the survey data. Qualitative methods included two focus group discussions with 24 nurses and midwives, and six key informant interviews with stakeholders (maternity matrons, responsible for maternal and child health, and district hospital managers). Thematic analysis was performed and selected quotations used to illustrate themes. The study took place in two district hospitals in Rwanda.ResultsQuantitative results found that 31 (57.4%) participants used the SDA four to six times per week. Many participants felt more confident (53.7%) and better at their job (40.7%) since having the SDA. Likert scale survey responses (1–5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that SDA is easy to use (Mean = 4.46), is an effective decision support tool (4.63), and training tool (4.65). Qualitative results included themes on perceived usefulness; professional growth acquired through the use of the SDA; SDA, an empowering, intuitive, and user-friendly technology; desired SDA features and functions; benefits of SDA as perceived by key informants, and future use of the SDA.ConclusionsThe nurses and midwives perceive the SDA as having improved their ability to manage childbirth complications. Key stakeholders also perceive the SDA as a useful tool with a reasonable cost and recommend its implementation in routine practices. This study deepens the understanding of the potential benefits of mHealth such as the SDA in low-income settings, like Rwanda. It also provides more evidence on the impact of mHealth in assuring quality BEmONC.

Nurses’ knowledge in the early detection and management of acute kidney injury in selected referral hospitals in Rwanda

&#x0D; &#x0D; &#x0D; INTRODUCTION: Acute kidney injury (AKI) is a global health issue, and its prevalence is higher in low- and middle-income countries (LMICs). The knowledge of nurses in the early detection and management of AKI has rarely been explored in the current literature; thus, this study aims to assess the knowledge of nurses in the early detection and management of patients with AKI in Rwanda.&#x0D; METHODS: A cross-sectional research design was implemented for this study. The study setting included selected referral hospitals in Kigali. A convenience sample of 165 nurses was obtained and data was collected using a self-administered questionnaire. Analyses were made using descriptive and inferential statistics in SPSS version 21.&#x0D; RESULTS: Nurses' knowledge in the early detection and management of AKI was low. Receiving in-service training on AKI positively influenced their knowledge in the early detection (p-value= 0.049), whereas studying AKI in nursing school p-value = 0.035) and receiving in-service training on AKI (p-value= 0.008) were associated with knowledge of the management of AKI. CONCLUSION: AKI is a common and potentially life-threatening condition that prolongs hospital stay, increases resource utilization, and mortality risks. Nurses need to be more involved in the early identification and management of AKI as they mostly serve as frontline health care providers and their role of continuous patient monitoring.&#x0D; &#x0D; &#x0D;

The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting.

Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings. The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from "strongly disagree" to "strongly agree"). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC. Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the "share information" item was statistically significant. Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.

Exploring the lived experiences of parents caring for infants with gastroschisis in Rwanda: The untold story.

Pediatric surgery is a crucial pillar of health equity but is often not prioritized in the global health agenda, especially in low-and middle-income countries. Gastroschisis (GS) is a type of structural congenital anomaly that can be treated through surgical interventions. In Rwanda, neonatal surgical care is only available in one hospital. The experience of parents of children born with gastroschisis has not been previously studied in Rwanda. The objective of this study was to explore the lived experiences of parents of children diagnosed with GS in Rwanda. A qualitative study using a semi-structured interview guide was conducted. Parents who had children with gastroschisis and were discharged alive from the hospital in Rwanda were interviewed by trained data collectors, from May to July 2021. Data were transcribed, translated, and then coded using a structured code-book. Thematic analysis was conducted with the use of Dedoose software. Sixteen parents participated in the study. Five themes emerged from the data. They were: "GS diagnosis had a significant emotional impact on the parents", "Parents were content with the life-saving medical care provided for their children despite some dissatisfaction due to the delayed initiation of care and shortage of medications", "GS care was accompanied by financial challenges", "support systems were important coping mechanisms" and "the impact of GS care extended into the post-discharge period". Having a newborn with GS was an emotional journey. The lack of pre-knowledge about the condition created a shock to the parents. Parents found support from their faith and other parents with similar experiences. The experiences with the care received were mostly positive. The overall financial burden incurred from the medical treatment and indirect costs was high and extended beyond the hospital stay. Strengthening prenatal and hospital services, providing peer, spiritual and financial support could enhance the parents' experience.

Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda

BackgroundThe implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family’s financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE).MethodsThis study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group.ResultsAbout 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%.ConclusionTo ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Assessing the waiting time for emergency orthopedic surgery for open fractures – A 6-month review of records at one of the largest referral public hospitals in Rwanda

INTRODUCTION: The delay in surgical intervention for open fractures can have severe negative consequences. However, the delay for patients with open fractures presenting at Centre Hospitalier Universitaire de Kigali (CHUK), one of the largest public hospitals in Kigali, Rwanda, had not been studied. This study assessed the waiting time for surgery and compared it against the 6-hour (ideal time) and 24-hours (acceptable time) standards.METHODS: A review of the postoperative register and patients’ records was conducted. All medical charts of open fracture cases between April and September 2018 were audited. A surgical case was considered significantly delayed if the time interval from patient arrival at the emergency room to the operation theater was longer than 24 hours. The demographics, acuity level, insurance status and work shifts, were assessed using bi- and multivariate analysis.RESULTS: A total of 115 open fracture case files were audited. From arrival at the emergency room to surgery, the median time was 41 hours (IQR 21, 93). Only 3 (2.6%) were operated within 6 hours and 38 (33%) within 6 to 24 hours. The main factor contributing to the delay was obtaining orthopedic consultation note and documenting the decision to operate (median 10 hours, IQR 4 to 17). Meanwhile, the designated emergency theater was not utilized for a total of 18 hours per day, especially during night shifts.CONCLUSION: There was a significant delay in obtaining emergency orthopedic consultation and, thus, the timing of the surgical treatment. Examining the patient flow system in orthopedic surgical care delivery is needed in order to maximize theater utilization at this urban university hospital.

Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda.

ObjectivesCraniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates.Study DesignThis prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020.SettingUrban referral center in resource-limited setting.MethodsEpidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications.ResultsFifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038).ConclusionDelay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.