Georges Ntakiyiruta

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda

Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level.

Augmenting surgical capacity in resource-limited settings

www.thelancet.com Vol 380 August 25, 2012 713 Defi ciencies in access to surgical care in low-income and middle-income countries are well recognised. Despite the awareness and benchmarks generated by the Millennium Development Goals, most sub-Saharan African nations have a negative annual growth rate in the number of physicians compared with their population growth rate. In several sub-Saharan African nations, there are only 0·9 physicians per 1000 population, compared with 21 physicians per 1000 population in the UK and 28 per 1000 population in the USA. These trends raise concerns about the morbidity, mortality, and disability-adjusted life-years lost due to injury and diseases requiring surgical treatment (including obstetrics) in sub-Saharan Africa. Policy makers and health-care leaders in Rwanda, a nation with only 0·1 general surgeons per 100 000 population (compared with 6·4 per 100 000 in the USA), have recognised the substantial negative socioeconomic eff ect caused by such defi ciencies and have committed themselves to tackling these challenges. 5–7 A partnership has been created between the Faculty of Medicine at the National University of Rwanda and McGill University Health Centre, Canada, to build on the academic elements of the only surgical residency in Rwanda. A needs assessment was done revealing a substantial requirement to augment surgical capacity through growth of the existing programme. Historically, the residency training has been service based, with relatively few academic activities; a refl ection of an overwhelming clinical workload and substantial staff shortages. These factors have resulted in a low intake of residents into the programme. Through the partnership, a system-based curriculum was developed, which is divided into 2-week modules covering locally relevant topics of general surgery. Each module contains lectures, resident case presentations, a journal club, morbidity and mortality rounds, and module evaluation by the residents. A Canadian surgeon, whose subspecialty is matched to the module topic, participates on a rotating basis in daily academic and clinical activities. This surgeon is not meant to replace local faculty in their responsibilities, but rather functions as an educator, moderator, and facilitator for the programme. Most activities are implemented by local faculty and residents. All activities are supervised by local faculty. These principles promote local programme accountability and, in keeping with the concept of “train the trainer”, form the necessary foundation for programme sustainability and success. This paradigm improves on previous models addressing the high morbidity and mortality from injury and surgical disease. Such models range from short-term, service-provision programmes, which, although they provide an exceptional service to indiv idual patients, are heavily dependent on the donor organisation, to slightly longer programmes that focus on surgical education, such as essential surgical skills, and trauma. We now recognise that the highest impact programmes for increasing surgical capacity will be based on long-term partnerships focused on training of local physicians, thereby increasing information retention and sustain ability. For the implementation of productive programmes, there are several important principles: local motivation and accountability, establishment of strong partnerships, understanding the local environment, curricu lum development based on local needs and not on western models, early programme assessment, and substantial involvement of local partners for pro gramme development. Additionally, the focus should be on Augmenting surgical capacity in resource-limited settings 7 Jylha M. What is self-rated health and why does it predict mortality? Towards a unifi ed conceptual model. Soc Sci Med 2009; 69: 307–16. 8 Mackenbach JP, Simon JG, Looman CW, Joung IM. Self-assessed health and mortality: could psychosocial factors explain the association? Int J Epidemiol 2002; 31: 1162–68. 9 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38: 21–37. 10 Zavalaa DE, Bokongo S, John IA, et al. Implementing a hospital based injury surveillance system in Africa: lessons learned. Med Confl Surviv 2008; 24: 260–72. 11 Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011; 11: 109. 12 Rani M, Bonu S. Attitudes toward wife beating: a cross-country study in Asia. J Interpers Violence 2009; 24: 1371–97. 13 Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. 14 Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specifi c socioeconomic and behavioral correlates. PLoS One 2010; 5: e14252. 15 Lee J. Pathways from education to depression. J Cross Cult Gerontol 2011; 26: 121–35. 16 WHO. 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Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital.

OBJECTIVE To define the operations performed by surgical residents at a tertiary referral hospital in Rwanda to help guide development of the residency program. DESIGN Cross-sectional study of all patients operated by surgical residents from October 2012 to September 2013. SETTING University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali [CHUK]), a public, tertiary referral hospital in Kigali, Rwanda. PARTICIPANTS 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. RESULTS 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. CONCLUSIONS 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.

Burn management in sub-Saharan Africa: opportunities for implementation of dedicated training and development of specialty centers.

BACKGROUND In low- and middle-income countries burn injuries remain responsible for a large burden of death and disability. Given an annual worldwide incidence of almost 11 million new individuals affected per year, major burn injuries have a higher annual incidence than HIV and tuberculosis combined. METHODS A survey instrument was adapted for use as an international assessment tool and then used to measure the availability of personnel, materials, equipment, medicines, and facility resources in nine Rwandan hospitals, including three referral centers. RESULTS Forty-four percent of surveyed hospitals had a dedicated acute-care burn ward, while two-thirds had intensive care options. Relevant wound-care supplies were widely available, but gaps in the availability of critical pieces of equipment such as monitors, ventilators, infusion pumps, electrocautery, and dermatomes were discovered in many of the surveyed institutions, including referral hospitals. Early excision and grafting were not performed in any of the hospitals and there were no physicians with specialty training in burn care. CONCLUSIONS Whereas all surveyed hospitals were theoretically equipped to handle the initial resuscitation of burn patients, none of the hospitals were capable of delivering comprehensive care due to gaps in equipment, personnel, protocols, and training. Accordingly, steps to improve capacity to care for those with thermal injury should include training of physicians specialized in critical care and trauma surgery, as well as plastic and reconstructive surgery. Consideration should be given to creation of national referral centers specializing in burn care.

Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda

BACKGROUND Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.

Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey

BACKGROUND In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Childrens Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health systems surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING The Harvard Sheldon Traveling Fellowship.

Contextual Challenges to Safe Surgery in a Resource-limited Setting: A Multicenter, Multiprofessional Qualitative Study

Objectives: Safe surgery should be available to all patients, no matter the setting. The purpose of this study was to explore the contextual-specific challenges to safe surgical care encountered by surgeons and surgical teams in many in low- and middle-income countries (LMICs), and to understand the ways in which surgical teams overcome them. Background: Optimal surgical performance is highly complex and requires providers to integrate and communicate information regarding the patient, task, team, and environment to coordinate team-based care that is timely, effective, and safe. Resource limitations common to many LMICs present unique challenges to surgeons operating in these environments, but have never been formally described. Methods: Using a grounded theory approach, we interviewed 34 experienced providers (surgeons, anesthetists, and nurses) at the 4 tertiary referral centers in Rwanda, to understand the challenges to safe surgical care and strategies to overcome them. Interview transcripts were coded line-by-line and iteratively analyzed for emerging themes until thematic saturation was reached. Results: Rwandan-described challenges related to 4 domains: physical resources, human resources, overall systems support, and communication/language. The majority of these challenges arose from significant variability in either the quantity or quality of these domains. Surgical providers exhibited examples of resilient strategies to anticipate, monitor, respond to, and learn from these challenges. Conclusions: Resource variability rather than lack of resources underlies many contextual challenges to safe surgical care in a LMIC setting. Understanding these challenges and resilient strategies to overcome them is critical for both LMIC surgical providers and surgeons from HICs working in similar settings.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District

Importance In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. Objective To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. Design, Setting, and Participants A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. Main Outcomes and Measures The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. Results Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. Conclusions and Relevance The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda

Introduction Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. Methods A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. Results 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. Conclusion A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.

Acute care surgery in Rwanda: Operative epidemiology and geographic variations in access to care

BACKGROUND Surgical management of emergent, life-threatening diseases is an important public health priority. The objectives of this study were to (1) describe acute care general surgery procedures performed at the largest referral hospital in Rwanda and (2) understand the geographic distribution of disease presentations and referral patterns. METHODS We performed a retrospective review of prospectively collected acute care surgery cases performed at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda between June 1 and December 1, 2011. Using Pearsons χ(2) test and the Fisher exact test, we compared cases originating from within Kigali and transfers from other provinces. Geospatial analyses also were used to further describe transfer patterns. RESULTS During the study period, 2,758 surgical interventions were performed, of which 25.6% (707/2,758) were general surgery operations. Of these, 45.4% (321/707) met the definition of acute care surgery. Only about one-third-32.3% (92/285)-of patients resided within Kigali, whereas about two-thirds-67.7% (193/285)-were transferred from other provinces. Most patients transferred from other provinces were younger than 18 years of age (40.4%; 78/193), and 83.0% (39/47) of patients older than 50 years of age originated from outside of Kigali. Specific operative indications and surgical procedures varied substantially between patients from Kigali and patients transferred from other provinces. CONCLUSION Emergency surgical conditions remain important contributors to the global burden of disease, particularly in low- and middle-income countries. Geographic variations exist in terms of operative diagnoses and procedures, which implies a need for improved access to surgical care at the district level with defined transfer mechanisms to greater-level care facilities when needed.