Non‐Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care

Abstract

BackgroundMost mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda.MethodsThis study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test.ResultsOf the 2660 patients who sought surgical care at the three hospitals, most were males (60.7 %). Many (42.6 %) were injured and 34.7 % of injuries were through road traffic crashes. Of presenting patients, 25.3 % had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0 %, p < 0.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0 %, respectively), but surgeons performed 90.6 % of the operations at Butaro District Hospital. For outcomes, 39.5 % of all patients were discharged without an operation, 21.1 % received surgery and were discharged, and 21.1 % were referred to tertiary facilities for surgical care.ConclusionSignificantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

“…However, patients at Butaro District Hospital, the only hospital with a general surgeon in our study, were significantly more likely to receive an operation compared to patients presenting to Kirehe and Rwinkwavu District Hospitals. This is consistent with other studies on surgical delivery in Rwanda [7], and can be attributed to either operations being conducted directly by the general surgeon or by general practitioners supervised by the general surgeon during surgical task sharing [2, 7, 17, 18]. In addition, the general surgeon treated the majority of the risky diagnoses (acute abdominal conditions and urological emergencies) and performed complex operations such as laparotomy reflecting improved access to major surgical treatment at a district hospital with skilled surgical provider.…”

“…While, 82.5% of operations occur in the district hospitals, most of these are cesarean sections [6]. For non-obstetric conditions, most patients present with trauma (42.6%), infection (22.5%), and general surgery including abdominal surgical conditions, hernias, soft tissues and skin conditions (21.1%), surgically resectable cancers (10.5%), urology (2.0%) and congenital defects (1.3%) [7]. Very few of the 42 district hospitals can provide emergency general surgery for patients presenting with these general surgical conditions or orthopedic conditions [6].…”

Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

“…11 In a descriptive study of nonobstetric operative conditions at 3 rural district hospitals in 2013 in Rwanda, 42.6% of 2,660 patients were diagnosed with injury. 12 As Africa develops economically, injuries are increasing in severity and numbers. 13 Patients with injuries have limited access to operative care due to geographical, cultural, and structural barriers, as well as costs, both surgical and collateral.…”

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing

“…Limited surgical specialists are often cited as a barrier to accessing surgical care at district hospitals11 16, 17, 18, 19. Although the cost of the surgeon's time contributed about 60 per cent of the total personnel costs, the overall cost of personnel was still lower than that of medicines or supplies.…”

“…In Rwanda, the majority (82·5 per cent) of surgical interventions are performed at district hospitals, and over half of these interventions are caesarean sections10. Patients needing a laparotomy or open fracture treatment, however, are commonly referred to tertiary hospitals11.…”