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1. Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

Author: Antonio Belli, Justine Davies, Lucia D'Ambruoso, Laura Bojke, Jean Marie Uwitonze, Sudha Jayaraman, Abebe Bekele, Agnieszka Ignatowicz, Aurore Nishimwe, Jean Claude Byiringiro, Jules Iradukunda, Nuhu Assuman, Jeanne Nyinawankusi, Verite Karangwa Cyubahiro, Jean Nepomuscene Sindikubwabo, Didier Hagumimana, Fabien Hagenimana, Jean Claude Semuto, Gilbert Rukundo, Ephrem Daniel Sheferaw, Oda Munyura, Rob Rickard, and Philbert Muhire
Subjects: Medicine
Abstract: Objective A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement.Design Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations.Setting The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients.Participants 24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites.Results Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making.Discussion We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.
Published: 2024
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2. Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

Author: Mediatrice Niyonsaba, Menelas Nkeshimana, Jean Marie Uwitonze, Justine Davies, Rebecca Maine, Jeanne D'Arc Nyinawankusi, McKenna Hunt, Rob Rickard, Sudha Jayaraman, and Melissa H. Watt
Subjects: Rwanda, Emergency medicine, Pre-hospital emergency care, Qualitative, Ambulance, Medicine, Medicine (General), R5-920
Abstract: Introduction: Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. Methods: In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants’ perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. Results: Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. Conclusion: Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.
Published: 2023
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3. Correction: Academic global surgical competencies: A modified Delphi consensus study.

Author: Natalie Pawlak, Christine Dart, Hernan Sacoto Aguilar, Emmanuel Ameh, Abebe Bekele, Maria F Jimenez, Kokila Lakhoo, Doruk Ozgediz, Nobhojit Roy, Girma Terfera, Adesoji O Ademuyiwa, Barnabas Tobi Alayande, Nivaldo Alonso, Geoffrey A Anderson, Stanley N C Anyanwu, Alazar Berhe Aregawi, Soham Bandyopadhyay, Tahmina Banu, Alemayehu Ginbo Bedada, Anteneh Gadisa Belachew, Fabio Botelho, Emmanuel Bua, Leticia Nunes Campos, Chris Dodgion, Michalina Drejza, Marcel E Durieux, Rohini Dutta, Sarnai Erdene, Rodrigo Vaz Ferreira, Zipporah Gathuya, Dhruva Ghosh, Randeep Singh Jawa, Walter D Johnson, Fauzia Anis Khan, Fanny Jamileth Navas Leon, Kristin L Long, Jana B A Macleod, Anshul Mahajan, Rebecca G Maine, Grace Zurielle C Malolos, Craig D McClain, Mary T Nabukenya, Peter M Nthumba, Benedict C Nwomeh, Daniel Kinyuru Ojuka, Norgrove Penny, Martha A Quiodettis, Jennifer Rickard, Lina Roa, Lucas Sousa Salgado, Lubna Samad, Justina Onyioza Seyi-Olajide, Martin Smith, Nichole Starr, Richard J Stewart, John L Tarpley, Julio L Trostchansky, Ivan Trostchansky, Thomas G Weiser, Adili Wobenjo, Elliot Wollner, and Sudha Jayaraman
Subjects: Public aspects of medicine, RA1-1270
Abstract: [This corrects the article DOI: 10.1371/journal.pgph.0002102.].
Published: 2023
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4. Academic global surgical competencies: A modified Delphi consensus study.

Author: Natalie Pawlak, Christine Dart, Hernan Sacoto Aguilar, Emmanuel Ameh, Abebe Bekele, Maria F Jimenez, Kokila Lakhoo, Doruk Ozgediz, Nobhojit Roy, Girma Terfera, Adesoji O Ademuyiwa, Barnabas Tobi Alayande, Nivaldo Alonso, Geoffrey A Anderson, Stanley N C Anyanwu, Alazar Berhe Aregawi, Soham Bandyopadhyay, Tahmina Banu, Alemayehu Ginbo Bedada, Anteneh Gadisa Belachew, Fabio Botelho, Emmanuel Bua, Leticia Nunes Campos, Chris Dodgion, Michalina Drejza, Marcel E Durieux, Rohini Dutta, Sarnai Erdene, Rodrigo Vaz Ferreira, Zipporah Gathuya, Dhruva Ghosh, Randeep Singh Jawa, Walter D Johnson, Fauzia Anis Khan, Fanny Jamileth Navas Leon, Kristin L Long, Jana B. A. Macleod, Anshul Mahajan, Rebecca G Maine, Grace Zurielle C Malolos, Craig D McClain, Mary T Nabukenya, Peter M Nthumba, Benedict C Nwomeh, Daniel Kinyuru Ojuka, Norgrove Penny, Martha A Quiodettis, Jennifer Rickard, Lina Roa, Lucas Sousa Salgado, Lubna Samad, Justina Onyioza Seyi-Olajide, Martin Smith, Nichole Starr, Richard J Stewart, John L Tarpley, Julio L Trostchansky, Ivan Trostchansky, Thomas G Weiser, Adili Wobenjo, Elliot Wollner, and Sudha Jayaraman
Subjects: Public aspects of medicine, RA1-1270
Abstract: Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.
Published: 2023
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5. Developing sustainable prehospital trauma education in Rwanda

Author: Ashley Rosenberg, Ignace Kabagema, Basil Asay, Jean Marie Uwitonze, Stephanie Louka, Menelas Nkeshimana, Gabin Mbanjumucyo, Luke Wolfe, Catherine Valukas, Theophile Dushime, and Sudha Jayaraman
Subjects: Trauma, Prehospital, Education, Africa, Rwanda, Medicine, Medicine (General), R5-920
Abstract: Introduction: Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices. Methods: A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated — SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests. Results: ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p
Published: 2020
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6. Development and Implementation of a Longitudinal Global Acute Care and Systems Strengthening Program

Author: Cybil S. Stingl, Kyle J. Alexander, James M. Dittman, Noah J. Hillerbrand, Karishma Popli, Amira Dalmazio, Nancy Valencia-Rojas, Aline Baghdassarian, Sudha Jayaraman, and Edgar B. Rodas
Subjects: Infectious and parasitic diseases, RC109-216, Public aspects of medicine, RA1-1270
Abstract: Background: Increasing access to safe, timely, and affordable acute care in low- and middle-income countries is a worldwide priority. Longitudinal curricula on systems of acute care have not been previously described. Objectives: The authors aimed to develop a novel four-year longitudinal curriculum for medical students addressing systems development across multiple acute care specialties. Methods: The authors followed Kern’s six-step framework for curriculum design. After review of literature, a group of medical students and school of medicine faculty conducted a targeted needs assessment. Foundational goals and objectives were adapted from the 39 interprofessional global health competencies by the Consortium of Universities for Global Health. Educational strategies include didactic sessions, workshops, journal clubs, preceptorships, and community outreach. Clinical years include specialty-specific emphases, guided junior-level discussions, and a capstone project. Yearly SWOT and Kirkpatrick model analyses served as program evaluation. Findings: The Curriculum Council approved the program in July 2019. During the first cycle, the program matriculated 30 students from classes of 2023 (14) and 2022 (16). The first year produced 11 interactive sessions, 6 journal clubs, and 10 seminars led by 31 faculty and guest speakers; 29/30 students completed requirements; 87 evaluations reflected 4.57/5 content satisfaction and 4.73/5 instructor satisfaction. The 2023 cohort reported improved understanding of session objectives (3.13/5 vs. 3.82/5, p = 0.03). Free-text feedback led to implementation of pre-reading standardization and activity outlines. Conclusion: The Program was well-received and successfully implemented. It meets the needs of graduating medical students interested in leading global health work. This novel student-faculty collaborative model could be applied at other institutions seeking to provide students with a foundation in global acute care.
Published: 2021
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7. Building Trauma and EMS Systems Capacity in Rwanda: Lessons and Recommendations

Author: Sudha Jayaraman, Faustin Ntirenganya, Menelas Nkeshimana, Ashley Rosenberg, Theophile Dushime, Ignace Kabagema, Jean Marie Uwitonze, Eric Uwitonize, Jeanne d’Arc Nyinawankusi, Robert Riviello, Irene Bagahirwa, Kenneth L. Williams, Elizabeth Krebs, Rebecca Maine, Paulin Banguti, Stephen Rulisa, Patrick Kyamanywa, and Jean Claude Byiringiro
Subjects: Infectious and parasitic diseases, RC109-216, Public aspects of medicine, RA1-1270
Abstract: Background: Surgical capacity building has gained substantial momentum. However, care at the hospital level depends on improved access to emergency services. There is no established model for facilitating trauma and EMS system capacity in LMIC settings. This manuscript describes our model for multi-disciplinary collaboration to advance trauma and EMS capacity in Rwanda, along with our lessons and recommendations. Methods: After high-level meetings at the Ministry of Health in Rwanda (MOH), in 2016, a capacity building plan focusing on improved clinical services, quality improvement/research and leadership capacity across prehospital and emergency settings. The main themes for the collaborative model included for empowerment of staff, improving clinical service delivery, and investing in systems and infrastructure. Funding was sought and incorporated into the Sector Wide Approaches to Planning process at the Ministry of Health of Rwanda. Findings: A shared mental model was created through a fully funded immersion program for Rwandese leaders from emergency medicine, nursing, prehospital care, and injury policy. Prehospital care delivery was standardized within Kigali through a train-the-trainers program with four new context-appropriate short courses in trauma, medical, obstetric/neonatal, and pediatric emergencies and expanded across the country to reach >600 staff at district and provincial hospitals. Forty-two protocols and checklists were implemented to standardize prehospital care across specialties. The WHO Trauma Registry was instituted across four major referral centers in the country capturing over 5,000 injured patients. Long-term research capacity development included Masters’ Degree support for 11 staff. Conclusions and Recommendations: This collaboration was highly productive in empowering staff and leadership, standardizing clinical service delivery in EMS, and investing in systems and infrastructure. This can be a useful model for trauma and EMS system capacity development in other LMICs.
Published: 2021
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8. Medications and patient safety in the trauma setting: a systematic review

Author: Jonathan H. DeAntonio, Tammy Nguyen, Gregory Chenault, Michel B. Aboutanos, Rahul J. Anand, Paula Ferrada, Stephanie Goldberg, Stefan W. Leichtle, Levi D. Procter, Edgar B. Rodas, Alan P. Rossi, James F. Whelan, V. Ramana Feeser, Michael J. Vitto, Beth Broering, Sarah Hobgood, Martin Mangino, Dayanjan S. Wijesinghe, and Sudha Jayaraman
Subjects: Trauma medication reconciliation, Med rec, Medication error, Surgery, RD1-811, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract: Abstract Background Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms “trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements.” Results The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.
Published: 2019
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9. The impact of data feedback on continuous quality improvement projects in Rwanda: A mixed methods analysis

Author: Helen E. Noble, John W. Scott, Jeanne D. Nyinawankusi, Jean M. Uwitonze, Ignace Kabagema, Rebecca G. Maine, Robert Riviello, Theophile Dushime, Samuel Enumah, Yiyuan Hu, Zeta Mutabazi, Jean C. Byiringiro, and Sudha Jayaraman
Subjects: Healthcare worker motivation, Rwanda, Pre-hospital emergency care, Continuous quality improvement, Medicine, Medicine (General), R5-920
Abstract: Background: Injuries are a leading cause of death and disability globally. Over 90% of injury-related mortality happens in low- and middle- income countries (LMICs). Rwanda's pre-hospital emergency system – Service d'Aide Medicale Urgente (SAMU) – and their partners created an electronic pre-hospital registry and Continuous Quality Improvement (CQI) project in 2014. The CQI showed progress in quality of care, sparking interest in factors enabling the project's success. Healthcare workers (HCW) are critical pieces of this success, yet we found a void of information linking pre-hospital HCW motivation to CQI programs like SAMU's. Methods: Our mixed methods approach included a 40-question survey using questions regarding HCW motivation. We scored the surveys to compare SAMU staff motivation with other HCWs in LMICs, and used a Likert scale to elicit agreement or disagreement. A semi-structured interview based on employee motivation theory qualitatively explored SAMU staff motivation using constructivist grounded theory. To find interview themes, two researchers independently performed line-by-line analysis. Results: SAMU staff received 5–21% higher motivation scores relative to other cohorts of HCWs in LMICs. Questions showing disagreement (five) asked about reprimand, damaged social standing, and ease of using the CQI technology. Three questions did not show consensus. Questions showing agreement (23) and strong agreement (nine) asked about organizational commitment, impact, and research improving patient care. Major themes were: improvements in quality of care, changes in job expectations, views on research, and positive experiences with data feedback. Conclusions: The CQI project provides constant feedback vital to building and sustaining successful health systems. It encourages communication, collaboration, and personal investment, which increase organizational commitment. Continuous feedback provides opportunities for personal and professional development by uncovering gaps in knowledge, patient care, and technological understanding. Complete, personalized data input encouraged by the CQI improves resource allocation, building robust health systems that improve HCW agency and motivation.
Published: 2020
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10. Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda

Author: Gabin Mbanjumucyo, Naomi George, Alexis Kearney, Naz Karim, Adam R. Aluisio, Zeta Mutabazi, Olivier Umuhire, Samuel Enumah, John W. Scott, Eric Uwitonze, Jeanne D’Arc Nyinawankusi, Jean Claude Byiringiro, Ignace Kabagema, Georges Ntakiyiruta, Sudha Jayaraman, Robert Riviello, and Adam C. Levine
Subjects: Medicine, Medicine (General), R5-920
Abstract: 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.
Published: 2016
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11. Effects of a novel low volume resuscitation solutions on coagulation and platelet function.

Author: Loren K Liebrecht, Jason Newton, Erika J Martin, Niluka Wickramaratne, Sudha Jayaraman, Jinfeng Han, Michel Aboutanos, Donald F Brophy, and Martin J Mangino
Subjects: Medicine, Science
Abstract: BackgroundNovel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers.MethodsWhole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate.FindingsFibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects.ConclusionsPEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.
Published: 2019
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12. Penetrating cardiac trauma and the use of emergent extracorporeal membrane oxygenation and therapeutic hypothermia: When cooler heads prevail

Author: Nathaniel Lee, Daniel Tang, and Sudha Jayaraman
Subjects: Surgery, RD1-811
Abstract: This is a case of penetrating chest trauma with traumatic arrest from cardiac tamponade, right and left ventriculotomies, mitral valve injury and ventricular septal defect. Patient underwent resuscitative thoracotomy converted to clamshell thoracotomy for haemorrhage control. Ventriculotomies were repaired on initial damage control operation. Extracorporeal membrane oxygenation cannulation and therapeutic cooling bridged to definitive cardiac repair several days later. Patient was discharged to an inpatient rehabilitation facility in 16 days. Keywords: Penetrating cardiac trauma, ECMO, Therapeutic hypothermia, Neuroprotection
Published: 2015
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13. Thromboelastographic analysis of novel polyethylene glycol based low volume resuscitation solutions.

Author: Loren K Liebrecht, Jason Newton, Erika J Martin, Nina Wickramaratne, Sudha Jayaraman, Jinfeng Han, Michel Aboutanos, Donald F Brophy, and Martin J Mangino
Subjects: Medicine, Science
Abstract: BACKGROUND:Low volume resuscitation (LVR) in shock prevents deleterious effects of crystalloid loading in pre-hospital settings. Polyethylene glycol 20,000 (PEG-20k) based LVR solutions are 20-fold more effective at maintaining perfusion and survival in shock compared to conventional crystalloids. The aim of this study was to determine coagulation and platelet function of whole blood treated with 10% PEG-20k. METHODS:Citrated blood from volunteers (n = 25) or early admission severely injured trauma patients (n = 9) were diluted 10% with various LVR solutions in a matched design with a paired volume control (saline), and studied using thromboelastography (TEG). FINDINGS:In healthy volunteers and patients, 10% PEG-20k significantly increased clot amplification time (k), decreased propagation (angle), maximal clot size and strength (MA), and the overall coagulation index (CI), but not clot initiation (R) or fibrinolysis (Ly30), relative to paired saline dilutional controls. Clinically, K, angle, and MA were just outside of the normal limits in volunteers but not in patients. No statistical differences existed between PEG-20k and Hextend (HES) in either patient population. In a dose response series using volunteer blood, all effects of 10% PEG-20k on TEG were reversed and normalized by lower concentrations (7.5% and 5%). Furthermore, 7.5% PEG-20k produced similar resuscitation effects as 10% PEG in rodent hemorrhagic shock models (n = 5). CONCLUSIONS:In conclusion, PEG-20k based LVR solutions produced a dose-dependent minor hypocoagulative state, possibly associated with changes in clot propagation and platelet function, which can be reversed by dose reduction in concentration while providing superior LVR, microvascular rescue, and lactate clearance compared to saline or starch.
Published: 2018
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14. Building research capacity in Africa: equity and global health collaborations.

Author: Kathryn M Chu, Sudha Jayaraman, Patrick Kyamanywa, and Georges Ntakiyiruta
Subjects: Medicine
Published: 2014
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15. Epidemiology of child injuries in Uganda: challenges for health policy

Author: Renee Yuen-Jan Hsia, Doruk Ozgediz, Sudha Jayaraman, Patrick Kyamanywa, Milton Mutto, and Olive C. Kobusingye
Subjects: road traffic, injuries, developing country, trauma, Public aspects of medicine, RA1-1270
Abstract: Globally, 90% of road crash deaths occur in the developing world. Children in Africa bear the major part of this burden, with the highest unintentional injury rates in the world. Our study aims to better understand injury patterns among children living in Kampala, Uganda and provide evidence that injuries are significant in child health. Trauma registry records of injured children seen at Mulago Hospital in Kampala were analysed. This data was collected when patients were seen initially and included patient condition, demographics, clinical variables, cause, severity, as measured by the Kampala trauma score, and location of injury. Outcomes were captured on discharge from the casualty department and at two weeks for admitted patients. From August 2004 to August 2005, 872 injury visits for children
Published: 2011
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16. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda.

Author: Sudha Jayaraman, Jacqueline R Mabweijano, Michael S Lipnick, Nolan Caldwell, Justin Miyamoto, Robert Wangoda, Cephas Mijumbi, Renee Hsia, Rochelle Dicker, and Doruk Ozgediz
Subjects: Medicine, Science
Abstract: BACKGROUND: We previously showed that in the absence of a formal emergency system, lay people face a heavy burden of injuries in Kampala, Uganda, and we demonstrated the feasibility of a basic prehospital trauma course for lay people. This study tests the effectiveness of this course and estimates the costs and cost-effectiveness of scaling up this training. METHODS AND FINDINGS: For six months, we prospectively followed 307 trainees (police, taxi drivers, and community leaders) who completed a one-day basic prehospital trauma care program in 2008. Cross-sectional surveys and fund of knowledge tests were used to measure their frequency of skill and supply use, reasons for not providing aid, perceived utility of the course and kit, confidence in using skills, and knowledge of first-aid. We then estimated the cost-effectiveness of scaling up the program. At six months, 188 (62%) of the trainees were followed up. Their knowledge retention remained high or increased. The mean correct score on a basic fund of knowledge test was 92%, up from 86% after initial training (n = 146 pairs, p = 0.0016). 97% of participants had used at least one skill from the course: most commonly haemorrhage control, recovery position and lifting/moving and 96% had used at least one first-aid item. Lack of knowledge was less of a barrier and trainees were significantly more confident in providing first-aid. Based on cost estimates from the World Health Organization, local injury data, and modelling from previous studies, the projected cost of scaling up this program was $0.12 per capita or $25-75 per life year saved. Key limitations of the study include small sample size, possible reporter bias, preliminary local validation of study instruments, and an indirect estimate of mortality reduction. CONCLUSIONS: Lay first-responders effectively retained knowledge on prehospital trauma care and confidently used their first-aid skills and supplies for at least six months. The costs of scaling up this intervention to cover Kampala are very modest. This may be a cost-effective first step toward developing formal emergency services in Uganda other resource-constrained settings. Further research is needed in this critical area of trauma care in low-income countries.
Published: 2009
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17. Surgical Capacity Building in Low- and Middle-Income Countries

Author: Rachel Koch, Abigail M. Felsted, Sargun Virk, Nobhojit Roy, and Sudha Jayaraman
Subjects: Pulmonary and Respiratory Medicine, Surgery
Published: 2022

18. Cost-Effectiveness of Lay First Responders Addressing Road Traffic Injury in Sub-Saharan Africa

Author: Alfred H. Thullah, Aiza Bustos, Canaan J. Hancock, Sudha Jayaraman, Krishnan Raghavendran, Zachary J. Eisner, and Peter G. Delaney
Subjects: Emergency Medical Services, Sub saharan, Cost estimate, Cost effectiveness, business.industry, Cost-Benefit Analysis, Emergency Responders, Gross domestic product, Geography, Emergency medical services, Per capita, Humans, Surgery, Prospective Studies, business, Socioeconomics, Road traffic, Africa South of the Sahara, Cost database
Abstract: Background To investigate the cost-effectiveness of training lay first responders (LFRs) to address road traffic injury (RTI) in sub-Saharan Africa (SSA) as the first step toward formal emergency medical services (EMS) development. Materials/Methods Cost data from five LFR programs launched between 2008 and 2019 in SSA was collected for LFR cost estimation, including three prospective collections from our group. We systematically reviewed literature and projected aggregate disability-adjusted life years (DALYs) from RTI in SSA that are addressable by LFRs to inform cost-effectiveness ratios ($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP) to determine the cost-effectiveness of LFRs addressing RTIs in SSA, following WHO-CHOICE guidelines, which state cost-effectiveness ratios less than GDP per capita are considered “very cost-effective.” Results Average annual cost per LFR trained across five programs was calculated to be 16.32USD (training=4.04USD, supplies=12.28USD). Following WHO and Disease Control Priorities recommendations for adequate emergency catchment, initial training of 750 LFRs per 100,000 people would cost 12,239.47USD with projected total annual DALYs averted equal to 227.7 per 100,000. Cost per DALY averted would therefore be 53.75USD with appropriate LFR availability, less than sub-Saharan African GDP per capita (1,585.40USD) and the lowest sub-Saharan African GDP per capita (Burundi, 261.20USD). Conclusion Following WHO-CHOICE guidelines, training LFRs can be a highly cost-effective means to address RTI morbidity and mortality across sub-Saharan Africa. With EMS unavailable for 91.3% of the African population, training LFRs can be an affordable first step toward formal EMS development.
Published: 2022

19. Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach

Author: Nobhojit Roy, Benedict C. Nwomeh, Randeep S. Jawa, Fiemu E. Nwariaku, Hernan Sacoto, Thomas G. Weiser, Girma Terfera, Sanjay Krishnaswami, Kathleen M. Casey, María Fernanda Jiménez, Doruk Ozgediz, Parisa Nicole Fallah, Raymond R. Price, Robert J. Dempsey, Kokila Lakhoo, Kathryn Chu, Abebe Bekele, Edgar B. Rodas, Michael S Lipnick, Mary T. Nabukenya, Robert Lane, Margaret J. Tarpley, Nensi M. Ruzgar, Gifty Kwakye, Sudha Jayaraman, Kristin L. Long, Emmanuel A. Ameh, Andrew B. Rees, John Tarpley, Walt Johnson, Haniee Chung, Nancy Valencia-Rojas, Steven M. Roser, Mamta Swaroop, Anusha Jayaram, Adnan Alseidi, Christopher M. Dodgion, Alexis Kahanu, Natalie Pawlak, Ahmadreza Abbaslou, Katayoun Madani, Nicole Starr, and Ziad C. Sifri
Subjects: medicine.medical_specialty, Latin Americans, Political science, Scopus, Graduate medical education, medicine, Global health, Surgery, Surgical education, Curriculum, Health equity, Accreditation
Abstract: Introduction We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. Methods We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. Results Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on “Health Equity and Social Justice” and only two mentioned “Social and Environmental Determinants of Health.” Only 22% (n = 4) were available as open-access. Conclusion Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.
Published: 2021

20. Decolonizing Global Surgery: Bethune Round Table, 2022 Conference on Global Surgery (virtual), June 16-18, 2022

Author: Fabio, Botelho, Karen, Gripp, Natalie, Yanchar, Abbie, Naus, Dan, Poenaru, Robert, Baird, Eliane, Reis, Leonildo, Farias, Ana Gabriely, Silva, Francisco, Viana, José Armando Pessoa, Neto, Sidney, Silva, Karen, Ribeiro, Luana, Gatto, Matheus Daniel, Faleiro, Miguel Godeiro, Fernandez, Lucas Sousa, Salgado, Natália Zaneti, Sampaio, Anna Luiza, Mendes, Rodrigo Vaz, Ferreira, Luiz, Marcião, Gabriel, Canto, José, Borges, Victor, Araújo, Gabrielly, Andrade, Joyce, Braga, Lívia, Bentes, Luís, Pinto, Henry T, Ndasi, Lahin M, Amlani, Ghislain, Aminake, Xavier, Penda, Serge, Tima, Aron, Lechtig, Kiran J, Agarwal-Harding, Marta, Whyte, Melinda, Fowler-Woods, Amanda, Fowler-Woods, Geraldine, Shingoose, Andrew, Hatala, Felicia, Daeninck, Ashley, Vergis, Kathleen, Clouston, Krista, Hardy, Laure, Djadje, Olga Mbougo, Djoutsop, Adrien Tangmi, Djabo, Ulrick Sidney, Kanmounye, Vanessa Nono, Youmbi, Patricia, Kakobo, Surafeal, Tafesse, Bisrat, Tamene, Zelalem, Chimdesa, Eden, Alemayehu, Birhanu, Abera, Dawit, Yifru, Fitsum Kifle, Belachew, Abenezer, Tirsit, Negussie, Deyassa, Bente E, Moen, Terje, Sundstrøm, Morten, Lund-Johansen, Mersha, Abebe, Rabia, Khan, Amha, Mekasha, Sophie, Soklaridis, Faizal, Haji, Juventine, Asingei, Eric P, O'Flynn, Diarmuid T, O'Donovan, Sophia C, Masuka, Doreen, Mashava, Faith V, Akello, Mpoki M, Ulisubisya, Helena, Franco, Abdoulie, Njai, Samuel, Simister, Micelle, Joseph, Pierre, Woolley, Deeptiman, James, Faye M, Evans, Ekta, Rai, Nobhojit, Roy, Varun, Bansal, Jyoti, Kamble, Anna, Aroke, Siddarth, David, Deepa, Veetil, Kapil Dev, Soni, Martin Gerdin, Wärnberg, Siddhesh, Zadey, João Ricardo Nickenig, Vissoci, Himanshu, Iyer, Ritika, Shetty, Anushka, Jindal, Gabriel, Ouma, Sayed Shah Nur Hussein, Shah, Carrie, Hinchman, Isaiah Michael, Rayel, Myles, Dworkin, Elijah, Mlinde, Collin J, May, Leonard N, Banza, Linda, Chokotho, Foster, Mbomuwa, Paul, Chidothi, Claude, Martin, William James, Harrison, Samuel, Paek, Lahin, Amlani, Togo, Adégné, Poudiougo, Abdoulmouinou, Traoré, Amadou, Traoré, Youssouf, Konaté, Madiassa, Dicko Moussa, Younoussa, Samaké, Moussa, Bah, Amadou, Touré, Hawa, Abramowitz, Laurent, Damilola Alexander, Jesuyajolu, Charles Arinze, Okeke, Otomi, Obuh, Damilola A, Jesuyajolu, Peace E, Ehizibue, Nnamdi E, Ikemefula, Jamike O, Ekennia-Ebeh, Abdulqudus A, Ibraham, Obinna E, Ikegwuonu, Thomas M, Diehl, Gisèle Juru, Bunogerane, Dan, Neal, Alain Jules, Ndibanje, Robin T, Petroze, Edmond, Ntaganda, Laurie, Milligan, Lydia, Cairncross, Francois, Malherbe, Liana, Roodt, Daniel K, Kyengera, Nathan N, O'Hara, David, Stockton, Alemayehu, Bedada, Marvin, Hsiao, Unami, Chilisa, Brianne, Yarranton, Nkhabe, Chinyepi, Georges, Azzie, Jeongyoon, Moon, Zachary, Rehany, Mehrshad, Bakhshi, Amy, Bergeron, Nathalie, Boulanger, Larry, Watt, Evan G, Wong, Natalie, Pawlak, Christine, Bierema, Emmanuel, Ameh, Abebe, Bekele, Maria F, Jimenez, Kokila, Lakhoo, Hernan, Sacato, Girma, Tefera, Doruk, Ozgediz, Sudha, Jayaraman, Ines, Peric, George, Youngson, Eric, Borgstein, Eric, O'Flynn, Joana, Simoes, Pamela A, Kingsley, Lior, Sasson, Hagi, Dekel, Alona Raucher, Sternfeld, Sagi, Assa, Racheli Sion, Sarid, Naizihijwa Joel, Mnong'one, Godwin Godfrey, Sharau, Stella Mihayo, Mongella, William Goldstein, Caryl, Bernard, Goldman, Rajan, Bola, Joseph, Ngonzi, Fanan, Ujoh, Raymond Bernard, Kihumuro, Ronald, Lett, Amanda, Torquato, Clara, Tavares, Gabriele, Lech, Anja, Džunic, Victoria, Gusa, Rosemary, Apeaii, Rafat, Noor, Isaac Ohene, Guyan, Jan, Christilaw, Stephen, Hodgins, Catherine, Binda, Kayoung, Heo, Samuel, Cheng, Hannah, Foggin, Grace, Hu, Sheila, Lam, Lydia, Feng, Alisha, Labinaz, Jayd, Adams, Rachel, Livergant, Sacha, Williams, Tamilarasy, Vasanthakumaran, Youcef, Lounes, Juan, Mata, Philip, Hache, Christian, Schamberg-Bahadori, Adaw, Monytuil, Emmanuel, Mayom, Shahrzad, Joharifard, Émilie, Joos, Amy, Paterson, Salome, Maswime, Anneli, Hardy, Rupert M, Pearse, Bruce M, Biccard, Mina, Salehi, Irena, Zivkovic, Sukhdeep, Jatana, Michael J, Flores, Kelsey E, Brown, Heather J, Roberts, Claire A, Donnelley, Ericka P, von Kaeppler, Edmund, Eliezer, Billy, Haonga, Saam, Morshed, and David W, Shearer
Published: 2022

21. Prehospital emergency obstetric and neonatal care train‐the‐trainers program in Rwanda

Author: Ignace Kabagema, Luke G. Wolfe, Jeanne D’Arc Nyinawankusi, Jean Marie Uwitonze, Basil Asay, Ashley Rosenberg, Amanda Ritter, David Ntirushwa, Emmanuel E Ndikuryayo, Sudha Jayaraman, Theophile Dushime, and Kenneth L. Williams
Subjects: Adult, Male, Mean square, Emergency Medical Services, medicine.medical_specialty, Inservice Training, Nursing Staff, Hospital, Baseline level, 03 medical and health sciences, 0302 clinical medicine, Pregnancy, Medical Staff, Hospital, medicine, Retrospective analysis, Humans, Childbirth, 030212 general & internal medicine, Retrospective Studies, 030219 obstetrics & reproductive medicine, business.industry, Mortality rate, Infant, Newborn, Rwanda, Obstetrics and Gynecology, General Medicine, Hospitals, District, medicine.disease, Test (assessment), Obstetrics, Emergency medicine, Female, Curriculum, Educational Measurement, Emergencies, Neonatology, Training program, business
Abstract: Objective Nearly 830 women die every day due to complications during pregnancy and childbirth, many are preventable. In Rwanda, to improve maternal mortality rates, our collaboration developed and implemented a context-specific, prehospital Emergency Obstetrics and Neonatal Course (EONC) and train-the-trainers program. Methods Two cohorts of staff participated in the program--SAMU EMS and staff from district hospitals. A two-day course was developed, consisting of skills stations, simulations and didactics. A 50-question assessment was administered to both cohorts before and after the courses. Student's t test and matched paired t-tests were used to evaluate the assessments through retrospective analysis of the data. Results EONC 1 median scores were 60% vs 92% (pre vs post), using matched-pair analysis of 20 participants. EONC 2 median scores were 52% vs 96% (pre vs post), using matched-pair analysis of participants. A one-way ANOVA mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores, F (1) = 8.35, p = 0.0059. Conclusion Optimal prehospital management of obstetric emergencies is essential to prevent needless mortality and morbidity. This study demonstrated that a context-appropriate prehospital obstetric and neonatal training program could be effectively developed and implemented for the SAMU team in Kigali, Rwanda.
Published: 2020

22. Developing sustainable prehospital trauma education in Rwanda

Author: Theophile Dushime, Catherine Valukas, Jean Marie Uwitonze, Menelas Nkeshimana, Stephanie Louka, Basil Asay, Luke G. Wolfe, Sudha Jayaraman, Gabin Mbanjumucyo, Ashley Rosenberg, and Ignace Kabagema
Subjects: Referral, Best practice, education, lcsh:Medicine, Endotracheal intubation, Needle Thoracostomy, Trauma, Education, 03 medical and health sciences, 0302 clinical medicine, Geochemistry and Petrology, Medicine, 030212 general & internal medicine, Prehospital, lcsh:R5-920, business.industry, lcsh:R, Rwanda, 030208 emergency & critical care medicine, Trauma care, medicine.disease, Cohort, Africa, Emergency Medicine, Original Article, Medical emergency, Training program, business, lcsh:Medicine (General), Gerontology, Venous cannulation
Abstract: Introduction: Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices. Methods: A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated — SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests. Results: ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p
Published: 2020

23. Developing Sustainable Prehospital Pediatric Care in Rwanda

Author: Ashley Rosenberg, Megan Wojick, Basil Asay, Kenneth Williams, Luke Wolfe, Aline Baghdassarian, Christian Umuhoza, Edmond Ntaganda, Ignace Kabagema, Jean Marie Uwitonze, Theophile Dushime, and Sudha Jayaraman
Subjects: Emergency Medical Services, Child, Preschool, Health Personnel, Pediatrics, Perinatology and Child Health, Emergency Medicine, Rwanda, Humans, General Medicine, Child
Abstract: Unintentional injury is the leading cause of death in children older than 1 year and disproportionately affects pediatric patients in low- and middle-income countries.Improved prehospital care capacity has demonstrated the ability to improve care and save lives. Our collaboration developed and implemented a sustainable prehospital emergency pediatrics care course (EPCC) for Service d'Aide Medicale Urgente, the public emergency medical service in Rwanda.A 1-day context-specific EPCC was developed based on international best practices and local feedback. Two cohorts were created to participate in the course. The first group, EPCC 1, was made of 22 Service d'Aide Medicale Urgente providers with preexisting knowledge on the topic who participated in the course and received training to lead future sessions. After completion of the EPCC1, this group led the second cohort, EPCC 2, which was composed of 26 healthcare providers from around Rwanda. Each group completed a 50 question assessment before and after the course.Emergency pediatrics care course 1 mean scores were 58% vs 98% (pre vs post), EPCC 2 mean scores were 49% vs 98% (pre vs post), using matched-pair analysis of 22 and 32 participants, respectively. When comparing unequal variances across the groups with a 2-tailed paired t test, EPCC 1 and EPCC 2 had a statistically significant mean change in pretest and posttest assessment test scores of 40% compared with 46%, P0.0001, with 95% confidence interval. A 1-way analysis of variance mean square analysis for the change in scores showed that regardless of the baseline level of training for each participant, all trainees reached similar postassessment scores (F(1) = 1.45, P = 0.2357).This study demonstrates effective implementation of a context-appropriate prehospital pediatric training program in Kigali, Rwanda. This program may be effective to support capacity development for prehospital care in Rwanda using a qualified local source of instructors.
Published: 2022

24. Collaboration for preliminary design of a mobile health solution for ambulance dispatch in Rwanda

Author: Jean Marie Uwitonze, Menelas Nkeshimana, RwandaBuild, Kigali, Rwanda, Fraterne Zephyrin Uwinshuti, Sudha Jayaraman, Ashley Rosenberg, Ignace Kabagema, Rob Rickard, Gabin Mbanjumucyo, and Theophile Dushime
Subjects: General Medicine
Abstract: The first 60 minutes after a trauma are described as “the golden hour.” For each minute of prehospital time, the risk of dying increases by 5% (Sampalis et al., 1999). Since 90% of the global burden of injuries occur in low- and middle-income countries and lead to 5.8 million deaths annually, addressing rapid access to emergency services is critical in these settings (Nielsen et al., 2012). In most low- and middle-income countries (LMICs), there are no formal trauma systems, and many lack organized prehospital care (Nielsen et al., 2012). Emergency medical dispatch and communication systems are a foundational component of emergency medical services (World Health Organization, 2005). Yet there are no established recommendations of creating these systems inLMICs.Rwanda, a country of over 12 million people, is a rapidly developing leader in East Africa. The Ministry of Health of Rwanda established the Service d’Aide Medicale Urgente (SAMU) in 2007, recognizing the need for public emergency medical services. SAMU’s national dispatch center receives roughly 3,000 calls per month through a national 912 hotline. It organizes regional transportation with 260 total ambulances located at hospitals throughout the country and provides prehospital emergency services in the capital city of Kigali with a fleet of 12 ambulances. In the city, each ambulance has a driver, nurse and anesthetist dispatched for every call. Emergency department nursing and anesthetist staff are dispatched from hospitals around the country to respond to regional emergencies. No formal prehospital cadre of the workforce exists although the SAMU staffhave extensive field experience in prehospital care. SAMU has several challenges to rapid prehospital emergency care including lack of addresses beyond the capital city, unclear location data in densely populated areas, complex communication processes with little information about health facility capacity, and no established electronic dispatch system. The average response time for SAMU ambulances was 59 minutes in 2018, but 39% of calls were not completed within the golden hour.
Published: 2020

25. Medication Reconciliation and Patient Safety in Trauma: Applicability of Existing Strategies

Author: Sudha Jayaraman, Laura A. Boomer, Michel B. Aboutanos, Martin J. Mangino, Dayanjan S. Wijesinghe, Stefan W. Leichtle, Sarah Hobgood, and Jonathan H. DeAntonio
Subjects: Pharmacy Technicians, Pharmacy, Commission, Pharmacists, Patient care, 03 medical and health sciences, Patient safety, Medication Reconciliation, Professional Role, 0302 clinical medicine, Trauma Centers, Patient-Centered Care, Electronic Health Records, Humans, Medicine, Child, Brain trauma, Aged, business.industry, Age Factors, Electronic medical record, medicine.disease, United States, Variety (cybernetics), 030220 oncology & carcinogenesis, Wounds and Injuries, 030211 gastroenterology & hepatology, Surgery, Patient Safety, Medical emergency, business
Abstract: The Joint Commission has established medication reconciliation as a National Patient Safety Goal, but it has not been studied much in trauma even though it is integral to safe patient care. This article reviews the existing medication reconciliation strategies and their applicability to the trauma setting. To perform medication reconciliation, hospitals use a variety of strategies including pharmacists or pharmacy technicians, electronic medical record tools, and patient-centered strategies. All of these strategies are limited in trauma. Subpopulations such as injured children, the elderly, and those with brain trauma are particularly challenging and are at risk for suboptimal care from inaccurate medication reconciliation. Further research is necessary to create a safe and efficient system for trauma patients.
Published: 2020

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

Author: Faustin Ntirenganya, Martin Munyaneza, Jennifer Rickard, and Sudha Jayaraman
Subjects: Adult, Male, medicine.medical_specialty, Adolescent, Referral, Peritonitis, Tertiary referral hospital, Logistic regression, Time-to-Treatment, Hospitals, University, Tertiary Care Centers, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Intervention (counseling), Health care, Chi-square test, Humans, Medicine, Medicine, African Traditional, Aged, Aged, 80 and over, business.industry, Rwanda, Middle Aged, Patient Acceptance of Health Care, medicine.disease, Cross-Sectional Studies, Socioeconomic Factors, Surgical Procedures, Operative, 030220 oncology & carcinogenesis, Emergency medicine, Female, 030211 gastroenterology & hepatology, Surgery, Health Expenditures, Presentation (obstetrics), business
Abstract: Peritonitis 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.This 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.Over 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).In 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.
Published: 2020

27. Prehospital epidemiology and management of injured children in Kigali, Rwanda

Author: Elizabeth Krebs, Sudha Jayaraman, Jean Marie Uwitonze, Vizir Nsengimana, Edmond Ntaganda, Christian Umuhoza, John D. Scott, Ignace Kabagema, Ashley Rosenberg, Robert Riviello, Theophile Dushime, and Myles Dworkin
Subjects: Male, Emergency Medical Services, medicine.medical_specialty, Adolescent, Psychological intervention, Poison control, Critical Care and Intensive Care Medicine, Suicide prevention, Occupational safety and health, 03 medical and health sciences, 0302 clinical medicine, Injury prevention, Epidemiology, medicine, Humans, Registries, 030212 general & internal medicine, Child, Retrospective Studies, business.industry, Incidence (epidemiology), Rwanda, 030208 emergency & critical care medicine, General Medicine, Emergency medicine, Emergency Medicine, Wounds and Injuries, Female, Cervical collar, business
Abstract: IntroductionPaediatric injuries are a major cause of mortality and disability worldwide, yet little information exists regarding its epidemiology or prehospital management in low-income and middle-income countries. We aimed to describe the paediatric injuries seen and managed by the prehospital ambulance service, Service d’Aide Medicale d’Urgence (SAMU), in Kigali, Rwanda over more than 3 years.MethodsA retrospective, descriptive analysis was conducted of all injured children managed by SAMU in the prehospital setting between December 2012 and April 2016.ResultsSAMU responded to a total of 636 injured children, 10% of all patients seen. The incidence of paediatric injury in Kigali, Rwanda was 140 injuries per 100 000 children. 65% were male and the average age 13.5 (±5.3). Most patients were between 15 and 19 years old (56%). The most common causes of injuries were road traffic incidents (RTIs) (447, 72%), falls (70, 11%) and assaults (50, 8%). Most RTIs involved pedestrians (251, 56%), while 15% (65) involved a bicycle. Anatomical injuries included trauma to the head (330, 52%), lower limb (280, 44%) and upper limb (179, 28%). Common interventions included provision of pain medications (445, 70%), intravenous fluids (217, 34%) and stabilisation with cervical collar (190, 30%).ConclusionIn Kigali, RTIs were the most frequent cause of injuries to children requiring prehospital response with most RTIs involving pedestrians. Rwanda has recently instituted several programmes to reduce the impact of paediatric injuries especially with regard to RTIs. These include changes in traffic laws and increased road safety initiatives.
Published: 2020

28. Estimating global injuries morbidity and mortality

Author: Zohreh Arefi, Rasmus Havmoeller, Pietro Ferrara, Vijay Kumar Chattu, Payman Salamati, Agegnehu Bante Getenet, Seyedeh Zahra Masoumi, Alexander C. Tsai, Andrew T Olagunju, Carl Abelardo T. Antonio, Morteza Abdullatif Khafaie, Tim Driscoll, Reza Rawassizadeh, Vishnu Renjith, Taras Kavetskyy, Ejaz Ahmad Khan, Gebreamlak Gebremedhn Gebremeskel, Richard C. Franklin, Naznin Hossain, Bhaskaran Unnikrishnan, Fariborz Mansour-Ghanaei, Arash Tehrani-Banihashemi, Morteza Naserbakht, Sangram Kishor Patel, Vera Marisa Costa, Suzanne Polinder, Ziad El-Khatib, Ashish Pathak, Mika Shigematsu, Bryan L. Sykes, David M. Pigott, Zeleke Aschalew Melketsedik, Hadi Hassankhani, Nuworza Kugbey, Lal B. Rawal, Masoud Foroutan, Dejana Braithwaite, Muluken Bekele Sorrie, Grant M. A. Wyper, Joht Singh Chandan, Akbar Barzegar, Hamid Safarpour, Kate E. LeGrand, Giulio Castelpietra, Dina Nur Anggraini Ningrum, Seth Christopher Yaw Appiah, Amin Soheili, Azeem Majeed, Akshaya Srikanth Bhagavathula, Nikolay Ivanovich Briko, Vahid Yazdi-Feyzabadi, Walter Mendoza, Ghulam Mustafa, Cuong Tat Nguyen, Pengpeng Ye, Mahesh P A, Carlos Miguel Rios González, Ahmad Daryani, Ibrahim Abdollahpour, Masoud Moradi, Haileab Fekadu Wolde, Mohammad Rabiee, Jaya Prasad Tripathy, Jack T Fox, Diep Ngoc Nguyen, Pallab K. Maulik, Ai-Min Wu, Félix Carvalho, Yun Jin Kim, Fatemeh Rajati, Nathaniel J Henry, David C. Schwebel, Ali H. Mokdad, Akine Eshete Abosetugn, Leonardo Roever, Ketema Bizuwork Gebremedhin, Khalid A Altirkawi, Hayimro Edemealem Merie, Farhad Ghamari, Ramesh Holla, Arash Sarveazad, Devasahayam J. Christopher, Kedir Hussein Abegaz, Suresh Jungari, Rohan Borschmann, Irfan Ullah, Nitin Joseph, Catalina Liliana Andrei, Abdallah M. Samy, Roman Topor-Madry, Michal Grivna, Ivo Rakovac, Mohammad Zamani, Antonio Maria Borzì, Atif Amin Baig, Mohsen Bayati, Mohammad Ali Mansournia, Fatemeh Heydarpour, Juanita A. Haagsma, Segun Emmanuel Ibitoye, Mehdi Sayyah, Teshome Abegaz Kamil, Fakher Rahim, Dillon O Sylte, Feng Sha, Palash Chandra Banik, Mohan Bairwa, Mariya Vladimirovna Titova, Yong Yu, Delia Hendrie, Spencer L. James, Anusha Ganapati Bhat, Seok Jun Yoon, Siavash Rahimi, Jost B. Jonas, Michael R. Phillips, Diana Silva, Amir Hossein Goudarzian, Samath D Dharmaratne, Roba Khundkar, Jemal Abdu Mohammed, Joemer C. Maravilla, Eleonora Dubljanin, Arun Balachandran, Arman Latifi, Randah R. Hamadeh, G. K. Mini, Alessandra C. Goulart, Andreea Mirica, Fatemeh Zarei, Habte Belete, Telma Zahirian Moghadam, Maseer Khan, Morenike Oluwatoyin Folayan, Atte Meretoja, Jasvinder A. Singh, Guilherme Borges, Yasir Waheed, Fahad Alanezi, Masoud Moghadaszadeh, Guoqing Hu, Archith Boloor, Luca Ronfani, Olayinka Stephen Ilesanmi, Vahid Rashedi, Mehran Shams-Beyranvand, Trang Huyen Nguyen, Yonatal Mesfin Tefera, Yousef Khader, Adnan Kisa, Simon I. Hay, Takeshi Fukumoto, Shahrzad Bazargan-Hejazi, Yuichiro Yano, Carlos A Castañeda-Orjuela, Suzanne Barker-Collo, Ghasem Azarian, Sezer Kisa, Basema Saddik, Leake Gebremeskel, Yetunde O. John-Akinola, Jennifer Rickard, Ilais Moreno Velásquez, Priya Rathi, Ali Bijani, Smita Pakhale, Francesco Saverio Violante, Neeraj Bedi, Efat Mohamadi, Deborah Carvalho Malta, Marek Majdan, Feleke Mekonnen Demeke, Chukwudi A Nnaji, Richard Ofori-Asenso, Prateek Rastogi, Xuefeng Liu, Monika Sawhney, Ayman Grada, Prasanna Mithra, Shanshan Li, Masood Ali Shaikh, Erin B Hamilton, Hung Chak Ho, Zichen Liu, Irini Chatziralli, Paulo A. Lotufo, Yuming Guo, Daniel N. 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Z.A., Memiah, P.T.N., Mendoza, W., Menezes, R.G., Mengesha, M.M., Meretoja, T.J., Meretoja, A., Merie, H.E., Mestrovic, T., Miazgowski, B., Miazgowski, T., Miller, T.R., Mini, G.K., Mirica, A., Mirrakhimov, E.M., Mirzaei-Alavijeh, M., Mithra, P., Moazen, B., Moghadaszadeh, M., Mohamadi, E., Mohammad, Y., Darwesh, A.M., Mohammadian-Hafshejani, A., Mohammadpourhodki, R., Mohammed, S., Mohammed, J.A., Mohebi, F., Bandpei, M.A.M., Molokhia, M., Monasta, L., Moodley, Y., Moradi, M., Moradi, G., Moradi-Lakeh, M., Moradzadeh, R., Morawska, L., Velásquez, I.M., Morrison, S.D., Mossie, T.B., Muluneh, A.G., Musa, K.I., Mustafa, G., Naderi, M., Nagarajan, A.J., Naik, G., Naimzada, M.D., Najaf, F., Nangia, V., Nascimento, B.R., Naserbakht, M., Nayak, V., Nazari, J., Ndwandwe, D.E., Negoi, I., Ngunjiri, J.W., Nguyen, T.H., Nguyen, C.T., Nguyen, D.N., Nguyen, H.L.T., Nikbakhsh, R., Ningrum, D.N.A., Nnaji, C.A., Ofori-Asenso, R., Ogbo, F.A., Oghenetega, O.B., Oh, I.-H., Olagunju, A.T., Olagunju, 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Yazdi-Feyzabadi, V., Ye, P., Yip, P., Yisma, E., Yonemoto, N., Yoon, S.-J., Youm, Y., Younis, M.Z., Yousef, Z., Yu, C., Yu, Y., Moghadam, T.Z., Zaidi, Z., Zaman, S.B., Zamani, M., Zandian, H., Zarei, F., Zhang, Z.-J., Zhang, Y., Ziapour, A., Zodpey, S., Dandona, R., Dharmaratne, S.D., Hay, S.I., Mokdad, A.H., Pigott, D.M., Reiner, R.C., Vos, T., Instituto de Saúde Pública da Universidade do Porto, James, Spencer L, Castle, Chris D, Dingels, Zachary V, Fox, Jack T, Adema, Bereket Duko, Yisma, Engida, Vos, Theo, and Public Health
Subjects: Male, Populations/contexts, 1106 Human Movement and Sports Sciences, Global injuries, population, 030204 cardiovascular system & hematology, Global Health, contexts, context, Global Burden of Disease, 0302 clinical medicine, Quality-Adjusted Life Year, Global health, 030212 general & internal medicine, Original Research, Data, populations/contexts, Incidence (epidemiology), Incidence, methodology, 3142 Public health care science, environmental and occupational health, Female, Public Health, TERRITORIES, Quality-Adjusted Life Years, descriptive epidemiology, Human, Disabilities, 195 COUNTRIES, statistical issue, 1117 Public Health and Health Services, 03 medical and health sciences, AGE, Life Expectancy, Environmental health, Injury prevention, SYSTEMATIC ANALYSIS, statistical issues, Humans, Mortality, Estimation, SEX-SPECIFIC MORTALITY, DISABILITY, Public Health, Environmental and Occupational Health, populations, Morbidity, Wounds and Injuries, 1106 Human Movement and Sports Sciences, 1117 Public Health and Health Services, 1701 Psychology, Quality-adjusted life year, Years of potential life lost, 1701 Psychology, Life expectancy, Estimates, Human medicine, populations/context
Abstract: Background. While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods. In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results. GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions. GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future. Seyed Aljunid acknowledges the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia for the approval and support to participate in this research project. Alaa Badawi acknowledges support by the Public Health Agency of Canada. Till Bärnighausen acknowledges support by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. Traolach Brugha received support from NatCen Social Research (http://natcen.ac.uk/) via NHS Digital and Department of Health and Social Care London, for the Adult Psychiatric Morbidity Survey (APMS) programme. Felix Carvalho received support from UID/MULTI/04378/2019 with funding from FCT/MCTES through national funds. Vera M Costa acknowledges support from grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006. Kebede Deribe is supported by a grant from the Wellcome Trust [grant number 201900] as part of his International Intermediate Fellowship. Tim Driscoll acknowledges that work on occupational risk factors was partially supported by funds from the World Health Organization. Eduarda Fernandes acknowledges support from UID/QUI/50006/2019 with funding from FCT/MCTES through national funds. Yuming Guo acknowledges support from Career Development Fellowships of the Australian National Health and Medical Research Council (numbers APP1107107 and APP1163693). Sheikh Mohammed Shariful Islam is funded by a Fellowship from National Heart Foundation of Australia and Institute for Physical Activity and Nutrition, Deakin University. Mihajlo Jakovljevic acknowledges support by the Ministry of Education Science and Technological Development of the Republic of Serbia through the Grant number OI175014; publication of results was not contingent upon Ministry's censorship or approval. Sudha Jayaraman acknowledges support from: NIH R21: 1R21TW010439-01A1 (PI); Rotary Foundation Global Grant #GG1749568 (PI); NIH P20: 1P20CA210284-01A1 (Co-PI) and DOD grant W81XWH-16-2-0040 (Co-I), during the period of this study. Yun Jin Kim acknowledges support from a grant from the Research Management Centre, Xiamen University Malaysia [grant number: XMUMRF/2018-C2/ITCM/0001]. Kewal Krishan is supported by UGC Centre of Advanced Study (CAS II) awarded to the Department of Anthropology, Panjab University, Chandigarh, India. Mansai Kumar acknowledges support from FIC/ NIH K43 1K43MH114320-01. Amanda Mason-Jones acknowledges support by the University of York. Mariam Molokhia is supported by the National Institute for Health Research Biomedical Research Center at Guy’s and St Thomas’s National Health Service Foundation Trust and King’s College London. Ilais Moreno Velasquez is supported by the Sistema Nacional de Investigación (SNI, Senacyt, Panama). Mukhammad David Naimzada acknowledges support from Government of the Russian Federation (Agreement No – 075-02-2019-967). Duduzile Ndwandwe acknowledges support from Cochrane South Africa, South African Medical Research Council. Stanislav S. Otstavnov acknowledges the support from the Government of the Russian Federation (Agreement No – 075-02-2019-967). Ashish Pathak acknowledges support from Indian Council of Medical Research (ICMR), New Delhi, India (Grant number 2013-1253). Michael R Phillips acknowledges support in part by a grant from the National Natural Science Foundation of China (No.81761128031). Abdallah M. Samy received a fellowship from the Egyptian Fulbright Mission Program. Milena Santric Milicevic acknowledges the support from the Ministry of Education, Science and Technological Development, Republic of Serbia (Contract No. 175087). Seyedmojtaba Seyedmousavi was supported by the Intramural Research Program of the National Institutes of Health, Clinical Center, Department of Laboratory Medicine, Bethesda, MD, USA. Rafael Tabarés-Seisdedos was supported in part by the national grant PI17/00719 from ISCIII-FEDER. Sojib Bin Zaman acknowledges support from an "Australian Government Research Training Program (RTP) Scholarship.
Published: 2020

29. Global Surgery Innovation at Academic Medical Centers: Developing a Successful Innovation Ecosystem

Author: Sudha Jayaraman, Catherine R. deVries, Jonathan Nellermoe, Sarah Schoenhals, Raymond R. Price, and Meghan Mali
Subjects: Knowledge management, business.industry, Ecosystem, Business
Published: 2021

30. Direct and indirect health effects of the nuclear power plant disasters: a review for health care professionals

Author: Ichiro Okano, Ashley Rosenberg, Myles Dworkin, Vijayashree Murthy, Sudha Jayaraman, and Kazuaki Takabe
Subjects: Materials Chemistry
Published: 2022

31. Building Trauma and EMS Systems Capacity in Rwanda: Lessons and Recommendations

Author: Ashley Rosenberg, Eric Uwitonize, Rebecca G. Maine, Theophile Dushime, Jean Claude Byiringiro, Patrick Kyamanywa, Sudha Jayaraman, Paulin Banguti, Robert Riviello, Jean Marie Uwitonze, Irene Bagahirwa, Stephen Rulisa, Kenneth L. Williams, Elizabeth Krebs, Ignace Kabagema, Menelas Nkeshimana, Faustin Ntirenganya, and Jeanne D’Arc Nyinawankusi
Subjects: Emergency Medical Services, Quality management, Referral, Policy Paper, Service delivery framework, media_common.quotation_subject, Mental model, MEDLINE, Collaborative model, Infectious and parasitic diseases, RC109-216, Pregnancy, medicine, Humans, Child, Empowerment, media_common, Infant, Newborn, Rwanda, Capacity building, General Medicine, medicine.disease, Quality Improvement, Emergency Medicine, Female, Medical emergency, Business, Public aspects of medicine, RA1-1270, Delivery of Health Care
Abstract: Background: Surgical capacity building has gained substantial momentum. However, care at the hospital level depends on improved access to emergency services. There is no established model for facilitating trauma and EMS system capacity in LMIC settings. This manuscript describes our model for multi-disciplinary collaboration to advance trauma and EMS capacity in Rwanda, along with our lessons and recommendations. Methods: After high-level meetings at the Ministry of Health in Rwanda (MOH), in 2016, a capacity building plan focusing on improved clinical services, quality improvement/research and leadership capacity across prehospital and emergency settings. The main themes for the collaborative model included for empowerment of staff, improving clinical service delivery, and investing in systems and infrastructure. Funding was sought and incorporated into the Sector Wide Approaches to Planning process at the Ministry of Health of Rwanda. Findings: A shared mental model was created through a fully funded immersion program for Rwandese leaders from emergency medicine, nursing, prehospital care, and injury policy. Prehospital care delivery was standardized within Kigali through a train-the-trainers program with four new context-appropriate short courses in trauma, medical, obstetric/neonatal, and pediatric emergencies and expanded across the country to reach >600 staff at district and provincial hospitals. Forty-two protocols and checklists were implemented to standardize prehospital care across specialties. The WHO Trauma Registry was instituted across four major referral centers in the country capturing over 5,000 injured patients. Long-term research capacity development included Masters’ Degree support for 11 staff. Conclusions and Recommendations: This collaboration was highly productive in empowering staff and leadership, standardizing clinical service delivery in EMS, and investing in systems and infrastructure. This can be a useful model for trauma and EMS system capacity development in other LMICs.
Published: 2021

32. Response Regarding: Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach

Author: Natalie Pawlak and Sudha Jayaraman
Subjects: Surgery
Published: 2022

33. Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Author: Giulio Castelpietra, Feng Sha, Khalid A Altirkawi, Seyedeh Zahra Masoumi, Gebreamlak Gebremedhn Gebremeskel, Ahmad Daryani, Ibrahim Abdollahpour, Simon I. Hay, Deborah Carvalho Malta, Erin B Hamilton, Kate E. LeGrand, Nikolay Ivanovich Briko, Ana-Laura Manda, Aziz Eftekhari, Irfan Ullah, Seth Christopher Yaw Appiah, Zichen Liu, Maida Umar, Shaimaa I. El-Jaafary, Marina Pinheiro, Farhad Ghamari, Milad Mohammadoo-Khorasani, Rajaram Yadav, Syed Mohamed Aljunid, Ramesh Holla, Farzad Jalilian, Jacek Jerzy Jozwiak, Omar Mukhtar Salman, Bayew Kelkay, Tanuj Kanchan, Irina Filip, Michael R. Phillips, Hamid Reza Tohidinik, Demelash Abewa Elemineh, Reza Malekzadeh, Tomasz Miazgowski, Diana Silva, Samath D Dharmaratne, Eleonora Dubljanin, Fatemeh Zare, Jasvinder A. Singh, Hagazi Gebremedhin Kassaye, Nathaniel J Henry, Venkatesh Maled, Girikumar Kumaresh, Alireza Rafiei, Zhi-Jiang Zhang, Arielle Wilder Eagan, Merhawi Gebremedhin Tekle, Gholamreza Roshandel, Jeevan Pereira, Tinuke O Olagunju, Olatunde Aremu, Mohammad Zamani, Mu'awiyyah Babale Sufiyan, Lidia Morawska, Bayisa Abdissa Baye, Eduarda Fernandes, Feleke Mekonnen Demeke, Beriwan Abdulqadir Ali, Ibrahim A Khalil, Hafte Kahsay Kebede, Songhomitra Panda-Jonas, Yuichiro Yano, Haileab Fekadu Wolde, Antonio Maria Borzì, Delia Hendrie, Azeem Majeed, Vahid Rashedi, Mehran Shams-Beyranvand, Ilais Moreno Velásquez, Derrick A Bennett, Roba Khundkar, Mohammed Madadin, Biniyam Sahiledengle Geberemariyam, Parul Puri, Lidia Sanchez Riera, Yetunde O. John-Akinola, Jennifer Rickard, Saeed Shahabi, Tiffany K. Gill, Jemal Abdu Mohammed, Alessandra C. Goulart, Mohiuddin Ahsanul Kabir Chowdhury, Roya Safari-Faramani, Pawan Faris, Farhad Moradpour, Guilherme Borges, Sadia Bibi, Bartosz Miazgowski, Wubalem Fekadu, Rakhi Dandona, Ali Reza Soltanian, Alaa Badawi, Amir Hasanzadeh, Hassan Haghparast Bidgoli, Carlos A Castañeda-Orjuela, Morteza Arab-Zozani, Vinay Nangia, Gaurav Gupta, Farkhonde Salehi, Isabela M. Benseñor, Rekha Thapar, Yasser S. Amer, Naohiro Yonemoto, Ahmad Ghashghaee, Amanda J. Mason-Jones, Marcela Agudelo-Botero, Ashraf Nabhan, Saeed Safari, Lorainne Tudor Car, Ayman Grada, Stanislav S. 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I., Mokdad, A. H., Reiner, R. C., Sartorius, B., Vos, T., James, Spencer L, Castle, Chris D, Dingels, Zachary V, Fox, Jack T, Adema, Bereket Duko, Yisma, Engida, and Vos, Theo
Subjects: Dánarmein, Fötlun, Dánartíðni, Lífslíkur, Life expectancy, 1106 Human Movement and Sports Sciences, burden of disease, Global Health, Global Burden of Disease, 0302 clinical medicine, Quality-Adjusted Life Year, Global health, Medicine, LIFE EXPECTANCY, 030212 general & internal medicine, POPULATION, Cause of death, Original Research, RISK, education.field_of_study, Global disease burdens, Injuries, Sjúkdómar, Incidence (epidemiology), Incidence, Population health, Burden of disease, Global, global, 3142 Public health care science, environmental and occupational health, 3. Good health, Descriptive epidemiology, Lýðheilsa, Quality-Adjusted Life Years, Public Health, TERRITORIES, descriptive epidemiology, Human, Population, 195 COUNTRIES, Humans, Life Expectancy, Morbidity, Wounds and Injuries, 1117 Public Health and Health Services, 03 medical and health sciences, AGE, SYSTEMATIC ANALYSIS, Mortality, education, Disability, SEX-SPECIFIC MORTALITY, business.industry, Faraldsfræði, DISABILITY, Public Health, Environmental and Occupational Health, Quality-adjusted life year, Years of potential life lost, Áverkar, 1701 Psychology, Human medicine, business, 030217 neurology & neurosurgery, Demography
Abstract: Publisher's version (útgefin grein), Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care., Bill and Melinda Gates Foundation OPP1152504, "Peer Reviewed"
Published: 2020

34. Pain in the Prehospital Setting in Rwanda: Results of a Mixed-Methods Quality Improvement Project

Author: K. Carlyle, Thierry Cyuzuzo, J. M. Uwitonze, D. Banerjee, Sudha Jayaraman, Ashley Rosenberg, J. P. D. Guidry, I. Kabagema, E. Uwitonze, T. Dushime, Myles Dworkin, and K. McIntyre
Subjects: Adult, Male, Medicine (General), Emergency Medical Services, Quality management, Article Subject, Patient demographics, Ambulances, Pain, Grounded theory, 03 medical and health sciences, 0302 clinical medicine, R5-920, Pain assessment, Ambulance service, Medicine, Humans, Pain Management, 030212 general & internal medicine, Pain Measurement, business.industry, Rwanda, Pain management, Middle Aged, medicine.disease, Quality Improvement, Anesthesiology and Pain Medicine, Cross-Sectional Studies, Neurology, Scale (social sciences), Female, Medical emergency, business, 030217 neurology & neurosurgery
Abstract: Introduction. Pain is a universal human experience tied to an individual’s health but difficult to understand. It is especially important in health emergencies. We performed a two-step quality improvement project to assess pain management by the SAMU ambulance service in Kigali, Rwanda, examining how pain is assessed and treated by ambulance staff to facilitate development of standardized guidelines of pain management in the prehospital setting, which did not exist at the time of the study. Materials and Methods. Deidentified ambulance service records from December 2012 to May 2016 were analyzed descriptively for patient demographics, emergency conditions, pain assessment, and medications given. Then, anonymized, semistructured interviews of ambulance staff were conducted until thematic saturation was achieved. Data were analyzed using a grounded theory approach. Results. SAMU managed 11,161 patients over the study period, of which 6,168 (55%) were documented as reporting pain and 5,010 (45%) received pain medications. Men had greater odds of receiving pain medications compared to women (OR = 3.8, 95% CI (3.5, 4.1), p Conclusions. We reviewed the existing quality of pain management in the prehospital setting in Kigali, Rwanda, assessed the SAMU staff’s perceptions of pain, and facilitated standardization of prehospital pain management through context-specific guidelines.
Published: 2020

35. Blunt cerebrovascular injury: The case for universal screening

Author: Michel B. Aboutanos, Debolina Banerjee, Stefan W. Leichtle, Robin Schrader, Sudha Jayaraman, Beth Torres, Edgar B. Rodas, and Beth Broering
Subjects: Adult, Male, medicine.medical_specialty, Computed Tomography Angiography, Critical Care and Intensive Care Medicine, 03 medical and health sciences, 0302 clinical medicine, Injury Severity Score, Predictive Value of Tests, Head Injuries, Closed, medicine, Humans, Mass Screening, Cerebrovascular Trauma, Computed tomography angiography, Retrospective Studies, Evidence-Based Medicine, medicine.diagnostic_test, business.industry, Trauma center, 030208 emergency & critical care medicine, Retrospective cohort study, Odds ratio, Middle Aged, Confidence interval, Blunt trauma, Predictive value of tests, Practice Guidelines as Topic, Critical Pathways, Surgery, Female, Radiology, business, Neck
Abstract: Background Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with computed tomography angiography of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. Methods Adult blunt trauma activations from July 2017 to August 2019 underwent full-body computed tomography scan including computed tomography angiography neck with a 128-slice computed tomography scanner. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. Results A total of 4,659 patients fulfilled the inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the American College of Surgeons Trauma Quality Improvement Program Best Practices Guidelines, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 72.2%, 64.9%, 6.8%, 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive expanded Denver criteria, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. Twenty-three percent (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4-12.1), 5.7 (2.2-15.1), and 2.7 (1.5-4.7), respectively. Eighty-three percent (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) a BCVI progression, and 8% (n = 10) a stroke. Conclusion Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. Level of evidence Diagnostic study, level III.
Published: 2020

36. The impact of data feedback on continuous quality improvement projects in Rwanda: A mixed methods analysis

Author: Jean Claude Byiringiro, Sudha Jayaraman, Robert Riviello, Rebecca G. Maine, John W. Scott, Zeta Mutabazi, Ignace Kabagema, Helen E. Noble, Theophile Dushime, Jean Marie Uwitonze, Jeanne D’Arc Nyinawankusi, Samuel Enumah, and Yiyuan Hu
Subjects: Quality management, lcsh:Medicine, Organizational commitment, Mixed methods analysis, Likert scale, 03 medical and health sciences, 0302 clinical medicine, Geochemistry and Petrology, Health care, Medicine, 030212 general & internal medicine, Continuous quality improvement, Medical education, lcsh:R5-920, Healthcare worker motivation, business.industry, Professional development, lcsh:R, Rwanda, 030208 emergency & critical care medicine, Employee motivation, Pre-hospital emergency care, Emergency Medicine, Original Article, business, lcsh:Medicine (General), Gerontology, Social status
Abstract: Background Injuries are a leading cause of death and disability globally. Over 90% of injury-related mortality happens in low- and middle- income countries (LMICs). Rwanda's pre-hospital emergency system – Service d'Aide Medicale Urgente (SAMU) – and their partners created an electronic pre-hospital registry and Continuous Quality Improvement (CQI) project in 2014. The CQI showed progress in quality of care, sparking interest in factors enabling the project's success. Healthcare workers (HCW) are critical pieces of this success, yet we found a void of information linking pre-hospital HCW motivation to CQI programs like SAMU's. Methods Our mixed methods approach included a 40-question survey using questions regarding HCW motivation. We scored the surveys to compare SAMU staff motivation with other HCWs in LMICs, and used a Likert scale to elicit agreement or disagreement. A semi-structured interview based on employee motivation theory qualitatively explored SAMU staff motivation using constructivist grounded theory. To find interview themes, two researchers independently performed line-by-line analysis. Results SAMU staff received 5–21% higher motivation scores relative to other cohorts of HCWs in LMICs. Questions showing disagreement (five) asked about reprimand, damaged social standing, and ease of using the CQI technology. Three questions did not show consensus. Questions showing agreement (23) and strong agreement (nine) asked about organizational commitment, impact, and research improving patient care. Major themes were: improvements in quality of care, changes in job expectations, views on research, and positive experiences with data feedback. Conclusions The CQI project provides constant feedback vital to building and sustaining successful health systems. It encourages communication, collaboration, and personal investment, which increase organizational commitment. Continuous feedback provides opportunities for personal and professional development by uncovering gaps in knowledge, patient care, and technological understanding. Complete, personalized data input encouraged by the CQI improves resource allocation, building robust health systems that improve HCW agency and motivation.
Published: 2020

37. First Rwanda National Trauma Symposium 2019: Challenges and priorities

Author: Innocent Nzeyimana, Assuman Nuhu, Sudha Jayaraman, Arsene Muhumuza, Theophile Dushime, Faustin Ntirenganya, Eric Benimana, Gilles Ndayisaba, Igance Kabagema, Busisiwe Bhengu, Elizabeth Krebs, Severien Muneza, Lambert Rutayisire, Ashley Rosenberg, Irene Bagahirwa, Jean Claude Byiringiro, Costica Uwitonze, Jeanne D’Arc Nyinawankusi, Ernest Nahayo, Gabin Mbanjumucyo, Menelas Nkeshimana, Ghislaine Umwali, and Jean Marie Uwitonze
Subjects: 03 medical and health sciences, 030505 public health, 0302 clinical medicine, Health Policy, Political science, Public Health, Environmental and Occupational Health, Library science, 030212 general & internal medicine, News, 0305 other medical science
Published: 2020

38. The epidemiology and prehospital care of motorcycle crashes in a sub-Saharan African urban center

Author: Myles Dworkin, Sudha Jayaraman, M. Niyonsaba, T. Dushime, Ashley Rosenberg, F. Z. Uwinshuti, Elizabeth Krebs, E. Kankindi, V. Nsengimana, I. Kabagema, and J. M. Uwitonze
Subjects: Adult, Male, medicine.medical_specialty, Emergency Medical Services, Sub saharan, Psychological intervention, Crash, Article, Young Adult, 0502 economics and business, Epidemiology, medicine, Emergency medical services, Financial strain, Urban Health Services, Humans, 0501 psychology and cognitive sciences, 050107 human factors, Africa South of the Sahara, 050210 logistics & transportation, business.industry, Incidence (epidemiology), Incidence, 05 social sciences, Public Health, Environmental and Occupational Health, Glasgow Coma Scale, Accidents, Traffic, Motorcycles, Emergency medicine, Wounds and Injuries, Female, business, Safety Research
Abstract: Road traffic crashes (RTCs) are common among motorcyclists in Kigali, Rwanda. The Service d’Aide Medicale Urgente (SAMU), a prehospital ambulance service, responds to many of these crashes. We aimed to describe motorcycle-related RTCs managed by SAMU. SAMU clinical data including demographic information, injury characteristics, and management details were analyzed descriptively for all motorcycle crashes occurring between December 2012 and July 2016. Every patient included in this study was injured. These patients all called the ambulance for their injuries after a motorcycle crash. There were 2,912 motorcycle-related RTCs over the study period, representing 26% of all patients managed by SAMU. The incidence of motorcycle crashes in Kigali was 258 crashes per 100,000 people over the 3.5-year study period. The average age was 30 years and 80% were males. The most common injuries were to the lower extremities (n = 958, 33%), head (n = 878, 30%), or upper extremities (n = 453, 16%). Injuries often resulted in fractures of extremities (n = 740, 25%) and external hemorrhage anywhere in the body (unspecified region; n = 660, 23%), yet few were severe based on the Kampala Trauma Score (n = 23, 2%) and Glasgow Coma Scale (n = 42, 1.5%). The most common interventions were provision of diclofenac (n = 1,526, 52.5%), peripheral intravenous (IV) access (n = 1,217, 42%), and administration of IV fluids (n = 1,048, 36%). Motorcycle-related RTCs represent a large burden of disease for patients treated by SAMU in Kigali, Rwanda. Young men are most at risk of injury, which imposes a financial strain on society. Though injuries occurred frequently, critical trauma cases from motorcycle crashes were uncommon. This may be a result of several initiatives in Rwanda to improve road safety.
Published: 2020
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39. Prehospital Emergency Obstetric Care by SAMU in Kigali, Rwanda

Author: Nsengimana, Ndikuryayo E, Ntirushwa D, M. Niyonsaba, Putman J, Sudha Jayaraman, Myles Dworkin, Ritter A, E. Kankindi, T. Dushime, I. Kabagema, Nyinawankusi J, Habihirwe R, Uwitonze, and Ashley Rosenberg
Subjects: education.field_of_study, medicine.medical_specialty, business.industry, Retained placenta, Childbearing age, Population, Emergency medicine, Medicine, business, medicine.disease, education, Threatened abortion, Obstetric care
Abstract: Background: In Rwanda, 52% of the population is female and 25% of the population is of childbearing age. We sought to understand the care provided for obstetric and gynecologic emergencies in the prehospital setting in Rwanda. Methods: Descriptive analysis was performed of demographic, indication, and intervention data for obstetric emergencies between December 2012 to May 2016 collected in a prospective database. Results: Nearly 16% of 11,161 patients seen by SAMU were for obstetric emergencies. The average age was 26 (+ 9). Delivery-related included labor (76%) and retained placenta (10%). Pre-delivery complications, such as threatened abortion (26%) and miscarriages (24.5%), were 19% of all obstetric cases and 3.5% of cases were postpartum problems such as postpartum hemorrhage (59%) and infection (31%). Of 826 women in labor, the average dilation was 5.8 + 3.1 cm. SAMU staff delivered 317 healthy babies in the prehospital setting. Conclusion: Obstetric emergencies need early recognition and intervention to support optimal outcomes for both mother and child. In Kigali, Rwanda, SAMU provides needed emergency obstetric care in the prehospital setting. Supporting their training on management of obstetric emergencies is likely to have substantial impact on maternal and fetal outcomes in the country.
Published: 2020

40. Fostering Trauma and Emergency Research Capacity in Rwanda Through Collaboration

Author: Menelas Nkeshimana, Jean Marie Uwitonze, Ashley Rosenberg, Sudha Jayaraman, Ignace Kabagema, Theophile Dushime, Robert Riviello, and Myles Dworkin
Subjects: medicine.medical_specialty, Medical education, Quality management, business.industry, Public health, Mentors, Equity (finance), Rwanda, Quality Improvement, Education, Mentorship, Emergency research, Political science, Health care, Epidemiology, medicine, Global health, Humans, Surgery, business, Delivery of Health Care, Emergency Treatment
Abstract: Objectives Access to effective emergent care would prevent 45% of all deaths in LMICs, however, trauma and emergency care remain largely neglected. Our collaboration in Rwanda to build prehospital trauma care led us to create a research mentorship program to enhance the ability of the local team to evaluate their system. Methods NIH grant funding had been previously obtained to establish standards for prehospital trauma care in Rwanda and build local research capacity. We created a research mentorship program that involved a surgical resident embedded locally tasked with 1) giving lectures on research, study design, interpretation, and writing, 2) providing mentorship for data interpretation and 3) supporting the development of abstracts, presentations, and publications. Results Four research teams identified high priority areas for quality improvement research. Research group meetings were held and involved mentored literature searches, critical review of published works, basics of study design, abstract writing and manuscript development. Abstracts were submitted and accepted to three international conferences. At this time 3 manuscripts have been accepted and are in production, 2 abstracts and 1 manuscript has been published. Eleven staff enrolled in master's degree programs in critical and nursing, epidemiology, public health and global health equity across three institutions. Conclusions Responsive health care systems need capacity for ongoing quality improvement and research. This is especially true to address the massive global burden of disease of trauma and emergency conditions. US academic surgical collaborations have tremendous research expertise that can contribute to improving health system capacity globally. Such collaborations offer the opportunity to set up the foundations of future academic productivity.
Published: 2019

41. Metabolomics and Precision Medicine in Trauma: The State of the Field

Author: Vigneshwar Kasirajan, Martin J. Mangino, Daniel Contaifer, Lorin M. Bachmann, Jonathan H. DeAntonio, Donald F. Brophy, Sudha Jayaraman, Michel B. Aboutanos, Alex B. Valadka, Rahul J. Anand, Rao R. Ivatury, Olena Glushakova, Dayanjan S. Wijesinghe, Gretchen M. Brophy, Urszula Osinska Warncke, and Ronald L. Hayes
Subjects: 0301 basic medicine, Resuscitation, medicine.medical_specialty, business.industry, MEDLINE, Vital signs, Psychological intervention, 030208 emergency & critical care medicine, Stroke volume, Critical Care and Intensive Care Medicine, Precision medicine, Article, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Age groups, Emergency Medicine, Humans, Metabolomics, Wounds and Injuries, Medicine, Precision Medicine, business, Intensive care medicine, Cause of death
Abstract: Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.
Published: 2018

42. Global Mortality From Firearms, 1990-2016

Author: Leticia Avila-Burgos, Mahdi Safdarian, Devina Nand, Tim Driscoll, David C. Schwebel, Andrew T Olagunju, Saeid Safiri, Vasily Vlassov, Dina Nur Anggraini Ningrum, Jost B. Jonas, Reyna A Gutiérrez, Delia Hendrie, Fentaw Tadese, Jagdish Khubchandani, Gessessew Bugssa Hailu, Bach Xuan Tran, Mekonnen Sisay, Amanda J. Mason-Jones, Mu'awiyyah Babale Sufiyan, Tommi Vasankari, Kyle J Foreman, Kristopher J. Krohn, Haftay Berhane Mezgebe, Christian Kieling, Nadia Akseer, Maheswar Satpathy, Reza Assadi, Christopher J L Murray, Tsegaye Tewelde Gebrehiwot, Ali Rowhani-Rahbar, Rakhi Dandona, Sudha Jayaraman, Rintaro Mori, Mustafa Z. Younis, Tesfay Mehari Atey, Ashish Awasthi, Amit Arora, Rodrigo Sarmiento-Suarez, Kingsley N. Ukwaja, Alan D. Lopez, Masoud Behzadifar, Ibrahim A Khalil, G Anil Kumar, George C Patton, Nancy Fullman, Nigussie Tadesse Sharew, André Faro, Guoqing Hu, Yousef Khader, Benn Sartorius, Suzanne Barker-Collo, Young-Ho Khang, Rajesh Sagar, Martha Híjar, Florian Fischer, Suliman Alghnam, Michael Kutz, Valery L. Feigin, Raimundas Lunevicius, Suzanne Polinder, Bryan L. Sykes, Van C. Lansingh, Adauto Martins Soares Filho, Mamta Swaroop, Jasvinder A. Singh, Mohsen Asadi-Lari, Afarin Rahimi-Movaghar, Spencer L. James, Alireza Esteghamati, Theo Vos, Tuomo J. Meretoja, Soewarta Kosen, Kerrie E. Doyle, Michael R. Phillips, Amaha Kahsay, Miloud Taki Eddine Aichour, Samath D Dharmaratne, James R. Bennett, Rohan Borschmann, Muhammed Magdy Abd El Razek, Rafael Tabarés-Seisdedos, Joseph S Salama, Salman Rawaf, Hamid Yimam Hassen, Heidi J. Larson, Ted R. Miller, Caitlin Hawley, Beatriz Paulina Ayala Quintanilla, Katya Anne Shackelford, Lalit Dandona, Vafa Rahimi-Movaghar, Aman Yesuf Endries, Guilherme Borges, Carlos A Castañeda-Orjuela, Shahrzad Bazargan-Hejazi, Soraya Seedat, Paul S. F. Yip, Juan Sanabria, Maziar Moradi-Lakeh, Farshad Pourmalek, Olayinka Stephen Ilesanmi, Masood Ali Shaikh, Mahfuzar Rahman, Richard Matzopoulos, Richard C. Franklin, Huyen Phuc Do, Mostafa Qorbani, Eric L. Ding, Mark A. Stokes, Rajaa Al-Raddadi, Stephen S Lim, Tung Thanh Tran, Dan J. Stein, Naohiro Yonemoto, Mohsen Naghavi, Vegard Skirbekk, Chhabi Lal Ranabhat, Walter Mendoza, Arebu Issa Bilal, Pengpeng Ye, Shai Linn, Ali H. Mokdad, Alexandra Brazinova, Nima Hafezi-Nejad, Julio Cesar Campuzano Rincon, Ashish Bhalla, Simon I. Hay, Deborah Carvalho Malta, David Teye Doku, Ivy Shiue, Farshad Farzadfar, Shafiu Mohammed, Aliasghar Ahmad Kiadaliri, Molly K. Miller-Petrie, Khurshid Alam, Milena M Santric Milicevic, Dumessa Edessa, Quyen Nguyen, Rajesh Kumar Rai, Paul I. Dargan, Reza Malekzadeh, Olatunde Aremu, David Laith Rawaf, Zoubida Zaidi, Hassan Magdy Abd El Razek, Carl Abelardo T. Antonio, Meysam Behzadifar, Josep Maria Haro, Ziad El-Khatib, Cuong Tat Nguyen, Laurie B. Marczak, Peter Njenga Keiyoro, Andrea Werdecker, Megha Arora, Neal D. Futran, Maysaa El Sayed Zaki, Diego De Leo, Faris Lami, Hassan Haghparast Bidgoli, Amir Kasaeian, Peter Memiah, Zulfiqar A Bhutta, Till Bärnighausen, Sadaf G. Sepanlou, Felix Akpojene Ogbo, Mihajlo Jakovljevic, Félix Carvalho, Yun Jin Kim, Global Burden Dis 2016 Injury Col, Universitat de Barcelona, and Public Health
Subjects: Male, Global Health, 01 natural sciences, 0302 clinical medicine, Firearm injury, Armas de Fuego, Homicide, Global health, Medicine, 030212 general & internal medicine, Young adult, Child, Aged, 80 and over, Mortality rate, Armes de foc, 11 Medical And Health Sciences, General Medicine, Middle Aged, 16. Peace & justice, Firearm suicide, Suicide, Gun ownership, Child, Preschool, Violencia, Female, Adult, Firearms, Adolescent, Uncertainty interval, Violence, Young Adult, 03 medical and health sciences, Age Distribution, General & Internal Medicine, Mortalitat, Humans, Vital registration, Suicidio, Sex Distribution, 0101 mathematics, Mortality, Aged, business.industry, 010102 general mathematics, Infant, Newborn, Infant, Heridas por Arma de Fuego, Homicidio, Mortalidad, Wounds, Gunshot, Human medicine, business, Demography
Abstract: IMPORTANCE: Understanding global variation in firearm mortality rates could guide prevention policies and interventions. OBJECTIVE: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. DESIGN, SETTING, AND PARTICIPANTS: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. EXPOSURES: Firearm ownership and access. MAIN OUTCOMES AND MEASURES: Cause-specific deaths by age, sex, location, and year. RESULTS: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P
Published: 2018

43. Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis

Author: Sudha Jayaraman, Eric Uwitonze, Robert Riviello, Rebecca G. Maine, Samuel Enumah, John W. Scott, Jean Claude Byiringiro, Ignace Kabagema, Jeanne D’Arc Nyinawankusi, and Yihan Hu
Subjects: Adult, Male, Emergency Medical Services, medicine.medical_specialty, Quality management, Adolescent, Psychological intervention, Interrupted Time Series Analysis, Young Adult, 03 medical and health sciences, 0302 clinical medicine, medicine, Global health, Humans, 030212 general & internal medicine, Quality of Health Care, General Environmental Science, Data collection, business.industry, Rwanda, 030208 emergency & critical care medicine, Middle Aged, medicine.disease, Quality Improvement, Summative assessment, Physical therapy, Health Resources, Wounds and Injuries, General Earth and Planetary Sciences, Female, Cervical collar, Metric (unit), Medical emergency, business, Program Evaluation
Abstract: Injury is a major cause of premature death and disability in East Africa, and high-quality pre-hospital care is essential for optimal trauma outcomes. The Rwandan pre-hospital emergency care service (SAMU) uses an electronic database to evaluate and optimize pre-hospital care through a continuous quality improvement programme (CQIP), beginning March 2014.The SAMU database was used to assess pre-hospital quality metrics including supplementary oxygen for hypoxia (O2), intravenous fluids for hypotension (IVF), cervical collar placement for head injuries (c-collar), and either splinting (splint) or administration of pain medications (pain) for long bone fractures. Targets of90% were set for each metric and daily team meetings and monthly feedback sessions were implemented to address opportunities for improvement. These five pre-hospital quality metrics were assessed monthly before and after implementation of the CQIP. Met and unmet needs for O2, IVF, and c-collar were combined into a summative monthly SAMU Trauma Quality Scores (STQ score). An interrupted time series linear regression model compared the STQ score during 14 months before the CQIP implementation to the first 14 months after.During the 29-month study period 3,822 patients met study criteria. 1,028 patients needed one or more of the five studied interventions during the study period. All five endpoints had a significant increase between the pre-CQI and post-CQI periods (p0.05 for all), and all five achieved a post-CQI average of at least 90% completion. The monthly composite STQ scores ranged from 76.5 to 97.9 pre-CQI, but tightened to 86.1-98.7 during the post-CQI period. Interrupted time series analysis of the STQ score showed that CQI programme led to both an immediate improvement of +6.1% (p=0.017) and sustained monthly improvements in care delivery-improving at a rate of 0.7% per month (p=0.028).The SAMU experience demonstrates the utility of a responsive, data-driven quality improvement programme to yield significant immediate and sustained improvements in pre-hospital care for trauma in Rwanda. This programme may be used as an example for additional efforts engaging frontline staff with real-time data feedback in order to rapidly translate data collection efforts into improved care for the injured in a resource-limited setting.
Published: 2017

44. Epidemiologic Characteristics of Pediatric Trauma Patients Receiving Prehospital Care in Kigali, Rwanda

Author: Jeanne DʼArc Nyinawankusi, Naz Karim, Samuel Enumah, Eric Uwitonze, Sudha Jayaraman, Jean Claude Byiringiro, Adam C. Levine, Alexis Kearney, Zeta Mutabazi, Naomi George, Olivier Félix Umuhire, John W. Scott, Gabin Mbanjumucyo, Adam R. Aluisio, Georges Ntakiyiruta, and Robert Riviello
Subjects: Male, medicine.medical_specialty, Adolescent, MEDLINE, Outcome assessment, 03 medical and health sciences, 0302 clinical medicine, Environmental health, Outcome Assessment, Health Care, Epidemiology, medicine, Humans, 030212 general & internal medicine, Child, Poverty, Retrospective Studies, business.industry, Public health, Accidents, Traffic, Rwanda, 030208 emergency & critical care medicine, Retrospective cohort study, General Medicine, Emergency department, medicine.disease, Hospitalization, Pediatrics, Perinatology and Child Health, Emergency Medicine, Wounds and Injuries, Female, Medical emergency, Emergency Service, Hospital, business, Pediatric trauma
Abstract: Pediatric trauma is a significant public health problem in resource-constrained settings; however, the epidemiology of injuries is poorly defined in Rwanda. This study describes the characteristics of pediatric trauma patients transported to the emergency department (ED) of the Centre Hospitalier Universitaire de Kigali by emergency medical services in Kigali, Rwanda.This cohort study was conducted at the Centre Hospitalier Universitaire de Kigali from December 2012 to February 2015. Patients 15 years or younger brought by emergency medical services for injuries to the ED were included. Prehospital and hospital-based data on demographics, injury characteristics, treatments, and outcomes were gathered.Data from 119 prehospital patients were accrued, with corresponding hospital data for 64 cases. The median age was 9.5 years, with most patients being male (67.2%). Injured children were most frequently brought from a street setting (69.6%). Road traffic injuries accounted for 69.4% of all mechanisms, with more than two thirds due to pedestrians being struck. Extremity trauma was the most common region of injury (53.1%), followed by craniofacial (46.8%). The most frequent ED interventions were analgesia (66.1%) and intravenous fluids (43.6%). Half of the 16 obtained head computed tomography scans demonstrated acute pathology. Twenty-eight patients (51.9%) were admitted, with 57.1% requiring surgery and having a median in-hospital care duration of 9 days (range, 1-122 days).In this cohort of Rwandan pediatric trauma patients, injuries to the extremities and craniofacial regions were most common. Theses traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of the associated injury patterns, may be beneficial in the Rwandan setting.
Published: 2017

45. Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation

Author: Paula Ferrada, Jinfeng Han, Jonathan H. DeAntonio, Naren Gajenthra Kumar, Julia Staschen, Loren Liebrecht, Beth Broering, James F. Whelan, Tammy Nguyen, Dayanjan S. Wijesinghe, Edgar B. Rodas, Stefan W. Leichtle, Michael J. Vitto, V. Ramana Feeser, Sarah Hobgood, Alan P. Rossi, Daniel Contaifer, Stephanie Goldberg, David Doan, Sudha Jayaraman, Levi D. Procter, Caroline Young, Luke G. Wolfe, Lorin M. Bachmann, Gregory Chenault, Christopher Chou, Michel B. Aboutanos, Rahul J. Anand, Jonathan D. Bennett, and Martin J. Mangino
Subjects: Male, medicine.medical_specialty, Pyridones, Administration, Oral, 030204 cardiovascular system & hematology, Critical Care and Intensive Care Medicine, Sensitivity and Specificity, Mass Spectrometry, Article, Dabigatran, 03 medical and health sciences, 0302 clinical medicine, Medication Reconciliation, Rivaroxaban, Liquid chromatography–mass spectrometry, Internal medicine, Positive predicative value, medicine, Humans, Clinical efficacy, 030212 general & internal medicine, Prospective Studies, Chromatography, High Pressure Liquid, Aged, business.industry, Study Type, Trauma center, Anticoagulants, 030208 emergency & critical care medicine, Healthy Volunteers, 3. Good health, Pyrazoles, Wounds and Injuries, Surgery, Apixaban, Female, business, medicine.drug
Abstract: BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.
Published: 2019

46. Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries

Author: Benedict C. Nwomeh, Jennifer Rickard, Martin Ekeke Monono, Ziad C. Sifri, Ai Xuan Holterman, Anthony G. Charles, Catherine Juillard, Sanjay Krishnaswami, Randeep S. Jawa, George P. Yang, Alain Chichom Mefire, S. Ariane Christie, Georges Alain Etoundi Mballa, Sudha Jayaraman, and Mamta Swaroop
Subjects: Low and middle income countries, business.industry, Development economics, Medicine, Surgery, business, Healthcare system
Abstract: In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.
Published: 2019

47. Effects of a novel low volume resuscitation solutions on coagulation and platelet function

Author: Donald F. Brophy, Martin J. Mangino, Erika J. Martin, Jinfeng Han, Niluka Wickramaratne, Jason Newton, Sudha Jayaraman, Michel B. Aboutanos, and Loren Liebrecht
Subjects: Male, Physiology, Polymers, Glycobiology, 030204 cardiovascular system & hematology, Fibrinogen, Biochemistry, Polyethylene Glycols, 0302 clinical medicine, Thrombasthenia, Animal Cells, Medicine and Health Sciences, Platelet, Materials, Multidisciplinary, medicine.diagnostic_test, biology, Chemistry, Thrombin, Hematology, Middle Aged, Healthy Volunteers, Body Fluids, Thrombelastography, Blood, Coagulation, Macromolecules, Physical Sciences, Medicine, Female, Anatomy, Cellular Types, Partial thromboplastin time, medicine.drug, Research Article, Platelets, Adult, Blood Platelets, medicine.medical_specialty, Platelet Function Tests, Resuscitation, Science, Materials Science, Fibrin, Blood Plasma, 03 medical and health sciences, Young Adult, Internal medicine, von Willebrand Factor, medicine, Humans, Blood Coagulation, Platelet-poor plasma, Glycoproteins, Blood Cells, Dose-Response Relationship, Drug, technology, industry, and agriculture, Biology and Life Sciences, Proteins, 030208 emergency & critical care medicine, Cell Biology, Crystalloid Solutions, Platelet Activation, Polymer Chemistry, Thromboelastography, Endocrinology, biology.protein
Abstract: BackgroundNovel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers.MethodsWhole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate.FindingsFibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects.ConclusionsPEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.
Published: 2019

48. Data-driven prehospital training to decrease motorcycle crash deaths in a Sub-Saharan African urban center

Author: F. Z. Uwinshuti, T. Dushime, Sudha Jayaraman, M. Niyonsaba, I. Kabagema, Myles Dworkin, Ashley Rosenberg, V. Nsengimana, Elizabeth Krebs, E. Kankindi, and J. M. Uwitonze
Subjects: Sustainable development, 050210 logistics & transportation, 05 social sciences, Public Health, Environmental and Occupational Health, Human factors and ergonomics, Poison control, Crash, Suicide prevention, Training (civil), Occupational safety and health, Article, 0502 economics and business, Injury prevention, 0501 psychology and cognitive sciences, Business, Socioeconomics, Safety Research, 050107 human factors
Abstract: The United Nations set an ambitious goal to reduce the number of road traffic fatalities by 50% by 2020 in Sustainable Development Goal 3.6, and improvements in the quality of post-crash care are p...
Published: 2019

49. Sepsis in two hospitals in Rwanda: A retrospective cohort study of presentation, management, outcomes, and predictors of mortality

Author: Aamer Syed, Jean Paul Mvukiyehe, Paulin Banguti, Dennis A. Hopkinson, Elisabeth D. Riviello, Thierry Cyuzuzo, Gaston Nyirigira, Myles Dworkin, Anne Tuyizere, Sudha Jayaraman, Christian Mukwesi, and Willy Mucyo
Subjects: Male, Critical Care and Emergency Medicine, Pulmonology, Blood Pressure, Vascular Medicine, Medical Conditions, 0302 clinical medicine, Medicine and Health Sciences, Vasoconstrictor Agents, Medicine, Hospital Mortality, 030212 general & internal medicine, Multidisciplinary, Medical record, Middle Aged, Shock, Septic, Hospitals, Intensive Care Units, Infectious Diseases, Cohort, Female, Research Article, Cohort study, Adult, medicine.medical_specialty, Referral, Death Rates, Science, Resuscitation, Sepsis, Respiratory Disorders, 03 medical and health sciences, Signs and Symptoms, Population Metrics, Humans, Retrospective Studies, Population Biology, business.industry, Septic shock, Rwanda, Glasgow Coma Scale, Biology and Life Sciences, 030208 emergency & critical care medicine, Retrospective cohort study, Length of Stay, medicine.disease, Respiration, Artificial, Health Care, Severe Sepsis, Health Care Facilities, Respiratory Infections, Emergency medicine, Fluid Therapy, Clinical Medicine, business
Abstract: Purpose Few studies have assessed the presentation, management, and outcomes of sepsis in low-income countries (LICs). We sought to characterize these aspects of sepsis and to assess mortality predictors in sepsis in two referral hospitals in Rwanda. Materials and methods This was a retrospective cohort study in two public academic referral hospitals in Rwanda. Data was abstracted from paper medical records of adult patients who met our criteria for sepsis. Results Of the 181 subjects who met eligibility criteria, 111 (61.3%) met our criteria for sepsis without shock and 70 (38.7%) met our criteria for septic shock. Thirty-five subjects (19.3%) were known to be HIV positive. The vast majority of septic patients (92.7%) received intravenous fluid therapy (median = 1.0 L within 8 hours), and 94.0% received antimicrobials. Vasopressors were administered to 32.0% of the cohort and 46.4% received mechanical ventilation. In-hospital mortality for all patients with sepsis was 51.4%, and it was 82.9% for those with septic shock. Baseline characteristic mortality predictors were respiratory rate, Glasgow Coma Scale score, and known HIV seropositivity. Conclusions Septic patients in two public tertiary referral hospitals in Rwanda are young (median age = 40, IQR = 29, 59) and experience high rates of mortality. Predictors of mortality included baseline clinical characteristics and HIV seropositivity status. The majority of subjects were treated with intravenous fluids and antimicrobials. Further work is needed to understand clinical and management factors that may help improve mortality in septic patients in LICs.
Published: 2021

50. The Cost of Responding to anAcinetobacterOutbreak in Critically Ill Surgical Patients

Author: Michael Klompas, Reza Askari, Sudha Jayaraman, Xiaoxia Liu, Yushan Jiang, Selwyn O. Rogers, and Stephen C Resch
Subjects: Male, Microbiology (medical), Critical Illness, Staffing, 030501 epidemiology, Disease Outbreaks, 03 medical and health sciences, 0302 clinical medicine, Drug Resistance, Multiple, Bacterial, Intensive care, Humans, Infection control, Medicine, 030212 general & internal medicine, health care economics and organizations, Retrospective Studies, Academic Medical Centers, Cross Infection, Infection Control, Acinetobacter, biology, business.industry, Critically ill, Overtime, Outbreak, Retrospective cohort study, Health Care Costs, Middle Aged, biology.organism_classification, medicine.disease, Infectious Diseases, Female, Surgery, Medical emergency, 0305 other medical science, business, Acinetobacter Infections
Abstract: Our institution had an outbreak of multi-drug-resistant Acinetobacter (MDRA) in 2011. We analyzed the costs of responding to this outbreak from the hospital's perspective.We estimated retrospectively the excess costs associated with an MDRA outbreak response at a major academic medical center, including the costs of staffing, supplies, administrative time, deep cleaning, and environmental testing. Differences in mean costs before and during the 2011 MDRA outbreak were analyzed using the Student t-test.The overall excess cost incurred during the outbreak response was $371,079 in 2011 U.S. dollars. The largest contributors were the extra resources needed to staff and clean the two intensive care units (ICUs) (78%). In the general surgery ICU, the mean weekly cost of nursing during the outbreak was $13,276 more for regular hours (+15%; p 0.01) than in the pre-outbreak period and $2,682 more for overtime hours (+86%; p = 0.02). In the trauma ICU, the cost was $20,746 more for regular hours (+24%; p 0.01) and $3,445 more for overtime hours (+124%; p 0.01). The costs of supplies ($13,036; +30%; p = 0.03) and gloves ($2,572; +48%; p = 0.01) also were greater during the outbreak. Administrative time, consumables, use of a surge pod, and environmental testing accounted for the remainder of the extra costs.Our institution incurred $371,079 in excess costs as a result of an MDRA outbreak. This figure does not include the costs related to treatment of the infections, loss of reimbursement because of hospital-acquired infection, legal services, or changes in staff morale, patient satisfaction, or hospital reputation. Strategies to prevent and control such outbreaks better have substantial value.
Published: 2016

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