Tertiary Referral Hospital In Rwanda Research Articles

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.

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;

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.

Upper Gastrointestinal Cancers in Rwanda: Epidemiological, Clinical and Histopathological Features in Patients Presenting to a Tertiary Referral Hospital

Background: Scant data on upper gastrointestinal cancers in Rwanda exist to guide potential prevention efforts. We evaluated the epidemiological, clinical and histopathological data among patients with gastric and esophageal tumors at a tertiary Referral Hospital in Rwanda. Methodology: We performed a retrospective review of histologically-confirmed esophageal and gastric cancers in adults age ≥ 18 yrs. old presenting to a university teaching hospital (Centre Hospitalier Universitaire de Butare) from 2014-2019. Variables included age at diagnosis, sex, clinical presentation, tumor location and histopathological type. Results: There were 149 upper gastrointestinal cancers, of which 137 (92%) were gastric and 12 (8%) were esophageal. Gastric cancer patients had a mean age at presentation of 56.9 ± 12.3 years (range 21 - 87). Presenting symptoms were epigastric pain (78.8%), weight loss (53.3%), post-prandial vomiting (52.6%), early satiety (29.9%), epigastric mass (24.8%), hematemesis (19.7%) and melena (16.8%). The location was antrum 50.3%, corpus 21.8%, fundus 8%, and cardia 8%. Tumor type was adenocarcinoma in 94.1%. Helicobacter pylori infection was present in 108 (78.8%). Esophageal cancer patients had a mean age of 54.4 ± 9.5 years (range 35 - 72). Presenting symptoms were dysphagia (100%) and weight loss (83%). The most common site was lower third esophagus (9/12), and adenocarcinoma cancer subtype accounted for 5/12 (41.6%) cases. Conclusion: Gastric adenocarcinoma was the most commonly diagnosed upper gastrointestinal cancers and was associated with a high prevalence of H. pylori infection. This study lays the foundation for future work to improve cancer outcomes in Rwanda.

Community- and Hospital-Acquired Infections in Surgical patients at a Tertiary Referral Hospital in Rwanda.

Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasing in globally. The aim of this study was to compare community-acquired infections (CAIs) and hospital-acquired infections (HAIs) and determine the rate of third-generation cephalosporin resistance and ESBL-PE at a tertiary referral hospital in Rwanda. This was a cross-sectional study of Rwandan acute care surgery patients with infection. Samples were processed for culture and susceptibility patterns using Kirby-Bauer disk diffusion method. Third-generation cephalosporin resistance and ESBL-PE were compared in patients with CAI versus HAI. Over 14months, 220 samples were collected from 191 patients: 116 (62%) patients had CAI, 59 (32%) had HAI, and 12 (6%) had both CAI and HAI. Most (n = 178, 94%) patients were started on antibiotics with third-generation cephalosporins (ceftriaxone n = 109, 57%; cefotaxime n = 52, 27%) and metronidazole (n = 155, 81%) commonly given. Commonly isolated organisms included Escherichia coli (n = 62, 42%), Staphylococcus aureus (n = 27, 18%), and Klebsiella spp. (n = 22, 15%). Overall, 67 of 113 isolates tested had resistance to third-generation cephalosporins, with higher resistance seen in HAI compared with CAI (74% vs 46%, p value = 0.002). Overall, 47 of 89 (53%) isolates were ESBL-PE with higher rates in HAI compared with CAI (73% vs 38%, p value = 0.001). There is broad and prolonged use of third-generation cephalosporins despite high resistance rates. ESBL-PE are high in Rwandan surgical patients with higher rates in HAI compared with CAIs. Infection prevention practices and antibiotic stewardship are critical to reduce infection rates with resistant organisms in a low-resource setting.

Factors Influencing Seeking and Reaching Care in Patients With Peritonitis in Rwanda

BackgroundPeritonitis is an emergency which frequently requires surgical intervention. The aim of this study was to describe factors influencing seeking and reaching care for patients with peritonitis presenting to a tertiary referral hospital in Rwanda. MethodsThis was a cross-sectional study of patients with peritonitis admitted to University Teaching Hospital of Kigali. Data were collected on demographics, prehospital course, and in-hospital management. Delays were classified according to the Three Delays Model as delays in seeking or reaching care. Chi square test and logistic regression were used to determine associations between delayed presentation and various factors. ResultsOver a 9-month period, 54 patients with peritonitis were admitted. Twenty (37%) patients attended only primary school and 15 (28%) never went to school. A large number (n = 26, 48%) of patients were unemployed and most (n = 45, 83%) used a community-based health insurance. For most patients (n = 44, 81%), the monthly income was less than 10,000 Rwandan francs (RWF) (11.90 U.S. Dollars [USD]).Most (n = 51, 94%) patients presented to the referral hospital with more than 24 h of symptoms. More than half (n = 31, 60%) of patients had more than 4 d of symptoms on presentation. Most (n = 37, 69%) patients consulted a traditional healer before presentation at the health care system. Consultation with a traditional healer was associated with delayed presentation at the referral hospital (P < 0.001). Most (n = 29, 53%) patients traveled more than 2 h to reach a health facility and this was associated with delayed presentation (P = 0.019). The cost of transportation ranged between 5000 and 1000 RWF (5.95-11.90 USD) for most patients and was not associated with delayed presentation (P = 0.449). ConclusionsIn this study, most patients with peritonitis present in a delayed fashion to the referral hospital. Factors associated with seeking and reaching care included sociodemographic characteristics, health-seeking behaviors, cost of care, and travel time. These findings highlight factors associated with delays in seeking and reaching care for patients with peritonitis.

A cross sectional survey of factors influencing mortality in Rwandan surgical patients in the intensive care unit

BackgroundManagement of critically ill patients is a challenge in low resource settings where there is a paucity of trained staff, infrastructure, resources, and drugs. We aimed to study the characteristics of surgical patients admitted in intensive care unit in a limited resource setting and determine factors associated with mortality. MethodsThis was a cross-sectional observational study of all surgical patients admitted to the intensive care unit of a tertiary referral hospital in Rwanda. Data included demographics, diagnosis, management, and outcomes. Logistic regression was used to determine factors associated with mortality. ResultsOver a 7-month period, there were 126 surgical patients admitted to the intensive care unit. Common diagnoses included head injury (n = 55, 44%), peritonitis (n = 33, 26%), brain tumor (n = 15, 12%), and trauma (n = 15, 12%). The overall mortality was 47% with the highest mortality seen in patients with peritonitis (76%). Factors associated with mortality on intensive care unit admission included hypotension (odds ratio, 12.50; 95% confidence interval, 3.04, 51.32) and having any comorbidity (odds ratio 5.69, 95% confidence interval, 1.58, 20.50). ConclusionSurgical patients admitted to the intensive care unit bear a significant mortality. Common surgical intensive care unit diagnoses include head injury and peritonitis. We recommend a review of the admission policy to optimize utility of the intensive care unit.

Preventability of maternal near miss and mortality in Rwanda: A case series from the University Teaching Hospital of Kigali (CHUK).

ObjectiveAssess the primary causes and preventability of maternal near misses (MNM) and mortalities (MM) at the largest tertiary referral hospital in Rwanda, Kigali University Teaching Hospital (CHUK).MethodsWe reviewed records for all women admitted to CHUK with pregnancy-related complications between January 1st, 2015 and December 31st, 2015. All maternal deaths and near misses, based on WHO near miss criteria were reviewed (Appendix A). A committee of physicians actively involved in the care of pregnant women in the obstetric-gynecology department reviewed all maternal near misses/ pregnancy-related deaths to determine the preventability of these outcomes. Preventability was assessed using the Three Delays Model.[1] Descriptive statistics were used to show qualitative and quantitative outcomes of the maternal near miss and mortality.ResultsWe identified 121 maternal near miss (MNM) and maternal deaths. The most common causes of maternal near miss and maternal death were sepsis/severe systemic infection (33.9%), postpartum hemorrhage (28.1%), and complications from eclampsia (18.2%)/severe preeclampsia (5.8%)/. In our obstetric population, MNM and deaths occurred in 87.6% and 12.4% respectively. Facility level delays (diagnostic and therapeutic) through human error or mismanagement (provider issues) were the most common preventable factors accounting for 65.3% of preventable maternal near miss and 10.7% maternal deaths, respectively. Lack of supplies, blood, medicines, ICU space, and equipment (system issues) were responsible for 5.8% of preventable maternal near misses and 2.5% of preventable maternal deaths. Delays in seeking care contributed to 22.3% of cases and delays in arrival from home to care facilities resulted in 9.1% of near misses and mortalities. Cesarean delivery was the most common procedure associated with sepsis/death in our population. Previous cesarean delivery (24%) and obstructed/prolonged labor (13.2%) contributed to maternal near miss and mortalities.ConclusionThe most common preventable causes of MNM and deaths were medical errors, shortage of medical supplies, and lack of patient education/understanding of obstetric emergencies. Reduction in medical errors, improved supply/equipment availability and patient education in early recognition of pregnancy-related danger signs will reduce the majority of delays associated with MNM and mortality in our population.

Epidemiological study of peritonitis among children and factors predicting mortality at a tertiary referral hospital in Rwanda

Background: Peritonitis is a commonly encountered paediatric surgical emergency. We conducted this study to identify common causes of peritonitis among Rwandan children and factors affecting morbidity and mortality.Methods: The study sample consisted of children with peritonitis who underwent surgical treatment at a tertiary referral hospital in Rwanda from 1 September 2015 to 28 February 2016. Collected data included sociodemographic, clinical, paraclinical, management, and outcome information. The analysis included Pearson's chi-square test and multivariate logistic regression to determine factors associated with morbidity and mortality.Results: Of 63 patients, 28 were female. Ages ranged from 4 months to 15 years, with a mean of 8.8 years. Seventy-three percent of patients presented within the first week of symptom onset. Appendicular perforation (25.4%) and gangrenous intussusception (23.8%) were the most common causes of peritonitis. Fourteen patients (22.2%) died. On multivariate analysis, factors associated with mortality included sepsis (odds ratio [OR] = 11.60; 95% confidence interval [CI] = 2.15 to 62.5; P = 0.004) and intensive care unit (ICU) admission (OR = 7.38; 95% CI = 1.20 to 45.3; P = 0.031).Conclusions: Peritonitis among children is common and bears significant morbidity and mortality at our centre. Training of healthcare providers in district hospitals for early recognition of peritonitis, and improved ICU care availability may reduce mortality secondary to peritonitis in children.Keywords: epidemiology; peritonitis; paediatric surgery; Rwanda

Antibiotic Use and Antimicrobial Resistance of Surgical Patients with Peritonitis at a Tertiary Referral Hospital in Rwanda.

There is growing recognition of the worsening problem of antibiotic resistance and the need for antibiotic stewardship in low-resource settings. The aim of this study was to describe antibiotic use and antimicrobial resistance in patients undergoing surgery for peritonitis at a Rwandan referral hospital. All surgical patients with peritonitis at a Rwandan referral hospital were enrolled. Prospective data were collected on epidemiology, clinical features, interventions, and outcomes. Antibiotic agents were prescribed and cultures were collected according to surgeon discretion. High risk for antibiotic treatment failure or death was defined as patients with severe sepsis, older than 70 years of age, tumor, or operating room delay more than 24 hours from hospital admission. Logistic regression was used to determine factors associated with high risk of antibiotic treatment failure or death. Over a six-month period, 280 patients underwent operation for peritonitis; 79 patients were excluded because no infectious etiology was identified at operation. Data on antibiotic usage were available for 165 patients. The most common diagnoses were intestinal obstruction (n = 43) and appendicitis (n = 36). Most patients received antibiotic agents, the most of of which being third-generation cephalosporins (n = 149; 90%) and metronidazole (n = 140; 85%). The mean duration of antibiotics was 5.1 days (range: 0-14). Overall, 80 (54%) patients were high-risk for antibiotic treatment failure or death. Risk for antibiotic treatment failure or death was associated with localized peritonitis (p = 0.001) and high American Society of Anesthesiologist score (p = 0.003). Cultures were collected from 33 patients and seven patients had an organism isolated. Escherichia coli was identified in in five surgical specimens and two 2 urine cultures. All Escherichia coli specimens showed resistance to cephalosporins. Broad antibiotic coverage with third-generation cephalosporins and metronidazole is common in Rwandan surgical patients with peritonitis. Areas for improvement should focus on choice and duration of antibiotic agents, tailored to underlying diagnosis and risk factors for antibiotic treatment failure or death. More data are needed on antibiotic resistance patterns to guide antimicrobial therapy.

Critical Care Management of Peritonitis in a Low-Resource Setting.

Management of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda. Data were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test. Over a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N = 17, 37.0%) and typhoid intestinal perforation (N = 6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2-4), and the median Surgical Apgar Score was 4 (range 0-6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p < 0.001), unplanned reoperation (28 vs. 10%, p < 0.001) and death (72 vs. 8%, p < 0.001). Patients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.

Necrotizing Soft Tissue Infections at a Tertiary Referral Hospital in Rwanda: Epidemiology and Risk Factors for Mortality.

Necrotizing soft tissue infections (NSTI) are emergency surgical conditions with severe physiologic and metabolic derangement. These infections are associated with increased rates of mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early. This prospective, observational cohort study includes all patients aged 12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We determined risk factors for mortality using multivariate logistic regression. We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male, and the mean age was 44years. The median duration of symptoms was 8days [interquartile range (IQR) 5-14]. The median length of hospital stay was 23days (IQR 8-41). The overall mortality was 26%. Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission [odds ratio (OR) 14.15, 95% confidence interval (CI) 0.96-208.01, p=0.050], renal failure (OR 8.92, 95% CI 1.55-51.29, p=0.014), infection located on the trunk (OR 5.60, 95% CI 0.99-31.62, p=0.050), and presence of skin gangrene (OR 4.04, 95% CI 1.18-13.76, p=0.026). In Rwanda, NSTI mortality is high and associated with advanced disease. It is imperative that efforts are focused on early consultation, diagnosis, and surgical management to prevent adverse outcomes.

Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda.

The surgical Apgar score (SAS) has demonstrated utility in predicting postoperative outcomes in a variety of surgical disciplines. However, there has not been a study validating the utility of the SAS in surgical patients in low-income countries. We conducted a prospective, observational study of patients undergoing laparotomy at a tertiary referral hospital in Rwanda and determined the ability of SAS to predict inpatient major complications and mortality. All adult patients undergoing laparotomy in a tertiary referral hospital in Rwanda from October 2014 to January 2015 were included. Data were collected on patient and operative characteristics. SAS was calculated and patients were divided into four SAS categories. Primary outcomes were in-hospital mortality and major complications. Rates and odds of in-hospital mortality and major complications were examined across the four SAS categories. Logistic regression modeling and calculation of c-statistics was used to determine the discriminative ability of SAS. 218 patients underwent laparotomy during the study period. One hundred and forty-three (65.6%) were male, and the median age was 34years (IQR 27-51years). The most common diagnosis was intestinal obstruction (97 [44.5%]). A high proportion of patients (170 [78%]) underwent emergency surgery. Thirty-nine (18.3%) patients died, and 61 (28.6%) patients had a major complication. In-hospital mortality occurred in 25 (50%) patients in the high-risk group, 12 (16%) in the moderate-risk group, 2 (3%) in the mild-risk group and there were no deaths in the low-risk group. Major complications occurred in 32 (64%) patients in the high-risk group, 22 (29%) in the moderate-risk group, 7 (11%) in the mild-risk group and there were no complications in the low-risk group. SAS was a good predictor of postoperative mortality (c-statistic 0.79) and major complications (c-statistic 0.75). SAS can be used to predict in-hospital mortality and major complications after laparotomy in a Rwandan tertiary referral hospital.

Aetiology and patterns of maxillofacial fractures in a tertiary referral hospital in Rwanda: two-year retrospective analysis

Aetiology and patterns of maxillofacial fractures in a tertiary referral hospital in Rwanda: two-year retrospective analysis

Introducing a Morbidity and Mortality Conference in Rwanda

To assess the structure, format, and educational features of a morbidity and mortality (M&M) conference in Rwanda. To determine factors associated with adverse events and to define opportunities for improvement. Retrospective, descriptive study of all cases presented at a surgical M&M conference over a 1-year period. Cases were reviewed for factors associated with adverse events and opportunities for improvement. Factors were characterized as delays in presentation, delays in diagnosis, delays in the operating room, errors in judgment, technical errors, advanced disease, and missing resources or malnutrition. Opportunities for improvement were categorized at the physician or hospital level. University Teaching Hospital of Kigali, a tertiary referral hospital in Rwanda. Cases presented at the surgical M&M conference over a 1-year period. Over a 1-year period, there were a total of 2231 operations with 131 in-hospital mortalities. There were 62 patients discussed at M&M conference. Of those discussed, there were 34 (55%) in-hospital deaths and 32 (52%) unplanned reoperations. Common diagnostic categories included 30 (48%) gastrointestinal, 15 (24%) trauma, and 10 (16%) neoplasm. Delays were commonly cited factors affecting outcomes. There were 22 (35%) delays in presentation, 23 (37%) delays in diagnosis or management, and 20 (32%) delays to the operating room. Errors in judgment occurred in 15 (24%) cases and technical errors occurred in 18 (29%) cases. Twenty-three (37%) patients had a critical resource missing and 17 (27%) patients had advanced disease. Malnutrition was associated with 11 (18%) adverse events. Participants identified opportunities for improvement in 48 (77%) cases. M&M conference can be used in a low-resource setting as an educational tool to address core competencies of practice-based learning and improvement and systems-based practice. It can define factors associated with surgical adverse events and opportunities for improvement at the physician and hospital levels.

Low-Cost Simulation to Teach Anesthetists' Non-Technical Skills in Rwanda.

Safe anesthesia care is challenging in developing countries where there are shortages of personnel, drugs, equipment, and training. Anesthetists' Non-technical Skills (ANTS)-task management, team working, situation awareness, and decision making-are difficult to practice well in this context. Cesarean delivery is the most common surgical procedure in sub-Saharan Africa. This pilot study investigates whether a low-cost simulation model, with good psychological fidelity, can be used effectively to teach ANTS during cesarean delivery in Rwanda. Study participants were anesthesia providers working in a tertiary referral hospital in Rwanda. Baseline observations were conducted for 20 anesthesia providers during cesarean delivery using the established ANTS framework. After the first observation set was complete, participants were randomly assigned to either simulation intervention or control groups. The simulation intervention group underwent ANTS training using low-cost high psychological fidelity simulation with debriefing. No training was offered to the control group. Postintervention observations were then conducted in the same manner as the baseline observations. The primary outcome was the overall ANTS score (maximum, 16). The median (range) ANTS score of the simulation group was 13.5 (11-16). The ANTS score of the control group was 8 (8-9), with a statistically significant difference (P = .002). Simulation participants showed statistically significant improvement in subcategories and in the overall ANTS score compared with ANTS score before simulation exposure. Rwandan anesthesia providers show improvement in ANTS practice during cesarean delivery after 1 teaching session using a low-cost high psychological fidelity simulation model with debriefing.

Missed or Delayed Cervical Spine or Spinal Cord Injuries Treated at a Tertiary Referral Hospital in Rwanda

This study was aimed at 1) reporting cases of missed cervical spine injuries treated at a tertiary-level hospital, King Faisal Hospital, Rwanda (KFH-R), and 2) identifying the causes of delaying the diagnosis. We prospectively collected data from patients with a missed or delayed cervical spine and/or cord injury treated at King Faisal Hospital, Kigali for a 12-month period (January 2012 to December 2012). The total number of cervical spine injury patients treated at our center was retrieved from the hospital admission registry. Forty-two patients with cervical spine or spinal cord injuries were treated at KFH-R in 2012, and 4 of them had a missed or delayed diagnosis. Clinical and radiologic findings of all 4 patients are presented, and the reasons for delaying diagnosis are identified. This study found that the cervical spine injuries were missed in 9.5% of the cervical spine trauma patients and resulted in a longer hospital stay for all 4 patients and severe disability in 1 patient (25%). The reasons for missed diagnoses in this study were 1) lack of cervical spine radiographic evaluation, 2) inadequate cervical spine radiographs to show the level of injury, 3) poor sensitivity of cervical spine plain radiography, 4) poor physical examination, 5) the presence of a distracting injury, and 6) poor sensitivity of radiographs and computed tomography scans for soft tissue injuries.

Mismatches in medicines reconciliation in acute medical in-patients at the chuk tertiary referral hospital in Rwanda

Mismatches in medicines reconciliation in acute medical in-patients at the chuk tertiary referral hospital in Rwanda

Identifying Gaps in the Surgical Training Curriculum in Rwanda Through Evaluation of Operative Activity at a Teaching Hospital

To define the operations performed by surgical residents at a tertiary referral hospital in Rwanda to help guide development of the residency program. Cross-sectional study of all patients operated by surgical residents from October 2012 to September 2013. University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali [CHUK]), a public, tertiary referral hospital in Kigali, Rwanda. All patient data were entered into the operative database by surgical residents at CHUK. A total of 2833 cases were entered into the surgical database. Of them, 53 cases were excluded from further analysis because no surgical resident was listed as the primary or assistant surgeon, leaving 2780 cases for analysis. There were 2780 operations involving surgical residents. Of them, 51% of procedures were classified under general surgery, 38% orthopedics, 7% neurosurgery, and 4% urology. Emergency operations accounted for 64% of the procedures, with 56% of those being general surgery and 35% orthopedic. Further, 50% of all operations were trauma, with 71% of those orthopedic and 21% general surgery. Surgical faculty were involved in 45% of operations as either the primary or the assistant surgeons, while the remainder of operations did not involve surgical faculty. Residents were primary surgeons in 68% of procedures and assistant surgeons in 84% of procedures. The operative experience of surgery residents at CHUK primarily involves emergency and trauma procedures. Although this likely reflects the demographics of surgical care within Rwanda, more focus should be placed on elective procedures to ensure that surgical residents are broadly trained.

Nursing interventions classification use in long-term care: By using the Nursing Interventions Classification, nurses at one long-term care facility were able to lessen the time and the cost of providing individualized patient care

Management of critically ill patients is a challenge in low resource settings where there is a paucity of trained staff, infrastructure, resources, and drugs. We aimed to study the characteristics of surgical patients admitted in intensive care unit in a limited resource setting and determine factors associated with mortality.This was a cross-sectional observational study of all surgical patients admitted to the intensive care unit of a tertiary referral hospital in Rwanda. Data included demographics, diagnosis, management, and outcomes. Logistic regression was used to determine factors associated with mortality.Over a 7-month period, there were 126 surgical patients admitted to the intensive care unit. Common diagnoses included head injury (n = 55, 44%), peritonitis (n = 33, 26%), brain tumor (n = 15, 12%), and trauma (n = 15, 12%). The overall mortality was 47% with the highest mortality seen in patients with peritonitis (76%). Factors associated with mortality on intensive care unit admission included hypotension (odds ratio, 12.50; 95% confidence interval, 3.04, 51.32) and having any comorbidity (odds ratio 5.69, 95% confidence interval, 1.58, 20.50).Surgical patients admitted to the intensive care unit bear a significant mortality. Common surgical intensive care unit diagnoses include head injury and peritonitis. We recommend a review of the admission policy to optimize utility of the intensive care unit.