Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study

Adam R Aluisio; Meagan A Barry; Kyle D Martin; Gabin Mbanjumucyo; Zeta A Mutabazi; Naz Karim; Rachel T Moresky; Jeanne D'Arc Nyinawankusi; Jean Claude Byiringiro; Adam C Levine

doi:10.1016/j.afjem.2018.10.002

Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study

Afr J Emerg Med. 2019 Mar;9(1):14-20. doi: 10.1016/j.afjem.2018.10.002. Epub 2018 Oct 13.

Affiliations

¹ Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA.
² Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda.
³ University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.
⁴ sidHARTe Program, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, USA.
⁵ Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, USA.
⁶ Service d'Aide Médicale Urgente, Kigali, Rwanda.

Abstract

Introduction: Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K).

Methods: At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results: From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016).

Discussion: In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.

Keywords: Africa; Emergency medicine; Mortality; Rwanda; Training.