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Background: Little is known regarding the effectiveness of pain protocols and guideline use in Emergency Departments (ED) in Sub-Saharan Africa. Therefore, to shed light on this research gap, this study had the following objectives: 1) to evaluate if the implementation of the Essential Pain Management (EPM) course combined with mentorship to use the World Health Organization (WHO) pain ladder-based protocol improves the quality of pain management among trauma patients at the ED of two teaching hospitals in Rwanda; and 2) to determine barriers to implementing the WHO pain ladder-based protocol among trauma patients in the same settings. Methods: This was a pre- and post-intervention study. The intervention was 1-day essential pain management training for ED clinical staff followed by 1 week mentorship on the use of the WHO pain ladder-based protocol. Results: We enrolled 261 patients (47.5% pre versus 52.5% post intervention), most of them were aged between 21 and 40 (60% pre versus 33% post intervention), and male (76% pre versus 73% post intervention). The quality of pain management at the ED improved as shown by the decrease of the number of patients with undocumented pain scores from 58% to 24% after the intervention (p-value > 0.001) and the increase of the number of patients with mild pain from 37% to 62% (p-value > 0.001). In addition, patients who were satisfied with the quality of pain management increased significantly from 42% before the intervention to 80% (p-value > 0.001). Barriers to the implementation of the WHO pain ladder-based protocol were identified related to staff (i.e. inadequate experience), to the hospital (i.e. poor documentation), and to patients (i.e. reluctance to report pain). Conclusion: The implementation of the EPM course along with mentorship to use the WHO pain ladder-based protocol significantly improved the quality of pain management for trauma patients in EDs of both referral hospitals. Despite this, some barriers remain unfixed such as inadequate staff experience, poor documentation, and patient's reluctance to report pain. Appropriate interventions should be implemented to address the identified barriers and ensure adequate pain management for patients admitted at EDs in public hospitals in Rwanda.

Abstract Background Sepsis is a life-threatening condition which may arise from infection in any organ system and requires early recognition and management. Healthcare professionals working in any specialty may need to manage patients with sepsis. Educating medical students about this condition may be an effective way to ensure all future doctors have sufficient ability to diagnose and treat septic patients. However, there is currently no consensus on what competencies medical students should achieve regarding sepsis recognition and treatment. This study aims to outline what sepsis-related competencies medical students should achieve by the end of their medical student training in both high or upper-middle incomes countries/regions and in low or lower-middle income countries/regions. Methods Two separate panels from high or upper-middle income and low or lower-middle income countries/regions participated in a Delphi method to suggest and rank sepsis competencies for medical students. Each panel consisted of 13–18 key stakeholders of medical education and doctors in specialties where sepsis is a common problem (both specialists and trainees). Panelists came from all continents, except Antarctica. Results The panels reached consensus on 38 essential sepsis competencies in low or lower-middle income countries/regions and 33 in high or upper-middle incomes countries/regions. These include competencies such as definition of sepsis and septic shock and urgency of antibiotic treatment. In the low or lower-middle income countries/regions group, consensus was also achieved for competencies ranked as very important, and was achieved in 4/5 competencies rated as moderately important. In the high or upper-middle incomes countries/regions group, consensus was achieved in 41/57 competencies rated as very important but only 6/11 competencies rated as moderately important. Conclusion Medical schools should consider developing curricula to address essential competencies, as a minimum, but also consider addressing competencies rated as very or moderately important.

Abstract Critical care is underprioritized. A global call to action is needed to increase equitable access to care and the quality of care provided to critically ill patients. Current challenges to effective critical care in resource-constrained settings are many. Estimates of the burden of critical illness are extrapolated from common etiologies, but the true burden remains ill-defined. Measuring the burden of critical illness is epidemiologically challenging but is thought to be increasing. Resources, infrastructure, and training are inadequate. Millions die unnecessarily due to critical illness. Solutions start with the implementation of first-step, patient care fundamentals known as Essential Emergency and Critical Care. Such essential care stands to decrease critical-illness mortality, augment pandemic preparedness, decrease postoperative mortality, and decrease the need for advanced level care. The entire healthcare workforce must be trained in these fundamentals. Additionally, physician and nurse specialists trained in critical care are needed and must be retained as leaders of critical care initiatives, researchers, and teachers. Context-specific research is mandatory to ensure care is appropriate for the patient populations served, not just duplicated from high-resourced settings. Governments must increase healthcare spending and invest in capacity to treat critically ill patients. Advocacy at all levels is needed to achieve universal health coverage for critically ill patients.

Abstract Background There are a number of factors that may contribute to high mortality and morbidity of women and newborns in low-income countries. These include a shortage of competent health care providers (HCP) and a lack of sufficient continuous professional development (CPD) opportunities. Strengthening the skills and building the capacity of HCP involved in the provision of maternal, newborn and child health (MNCH) is essential to ensure quality care for mothers, newborns and children. To address this challenge in Rwanda, mentorship of HCPs was identified as an approach that could help build capacity, improve the provision of care and accelerate the reduction in maternal and neonatal mortality and morbidity. In this paper, we describe the development and implementation of a novel mentorship model named Four plus One (4+ 1) for MNCH in Rwanda. Methods The mentorship model built on the basis of inter-professional collaboration (IPC) was developed in early 2017 through consultations with different key actors. The design phase included refresher courses in specific skills and training course on mentoring. Field visits were conducted in 10 hospitals from June 2017 to February 2020. Hospital management teams (MT) were involved in the development and implementation of this mentorship model to ensure ownership of the program. Results Upon completion of planned visits to each hospital, a total of 218 HCPs were involved in the process. Reports prepared by mentors upon each mentorship visit and compiled by Training Support and Access Model (TSAM) for MNCH’CPD team, highlighted the mothers and newborns who were saved by both mentors and mentees. Also, different logbooks of mentees showed how the capacity of staff was strengthened, thereby suggesting effectiveness of the model. Through different mentorship coordination meetings, the model was much appreciated by the MTs of hospitals, especially the IPC component of the model and confirmed the program ‘effectiveness. Conclusion The initiation of a mentorship model built on IPC together with the involvement of the leadership of the hospital may be the cause effect of reduction of specific mortality and improve MNCH in low resource settings even when there are a limited number of specialists in the health facilities.

Abstract Background Worldwide maternal mortality remains high, with approximately 830 maternal deaths occurring each day. About 90% of these deaths occur in low-income countries. Evidenced-based essential birth practices administered during routine obstetrical care and childbirth are key to reducing maternal and neonatal deaths. The WHO Safe Childbirth Checklist (SCC) is a low-cost tool designed to ensure birth attendants perform 29 essential birth practices (EBP) at four critical periods in the birth continuum. This study aimed to evaluate compliance with EBP in Masaka District Hospital both before and after the implementation of the WHO-SCC. Methods This quality improvement project took place in the Masaka District Hospital in Rwanda. Observations of the 29 EBPs were done before and after WHO SCC implementation. The implementation process consisted of providing training in the use of the checklist to all clinical staff and posting SCC posters at different locations in the maternity unit. Results A total 391 birth events were observed pre-intervention and 389 post-intervention. The overall EBP compliance rate increased from 46% pre-intervention to 56% post-intervention (P = 0.005). Significant improvements were seen in 11 out of 29 EBPs. Conclusion The implementation of the WHO SCC improved the overall EBP compliance rate in Masaka District Hospital. Determining the root cause of low compliance rate of some EBP may allow for more successful implementation of EBP interventions in the future. After further study, the SCC should be considered for scale up.