Standardization of Prehospital Care in Kigali, Rwanda

INTRODUCTION

Injury in the prehospital setting is among the leading causes of death worldwide.¹ The need for organized EMS systems in low and middle income countries (LMICs) has been well established; but as of 2015, trauma systems only existed in 10 LMICs with development primarily limited by cost.^2,3 The World Health Organization (WHO) encouraged prehospital trauma care systems development through formal resources with case studies from Thailand, Mexico, Romania, and Cambodia, where effective trauma and emergency systems were developed and tailored to local needs.⁴ Checklists have been shown to improve patient outcomes in the hospital and prehospital settings and have been promoted by the WHO in LMIC settings as a mechanism to standardize care delivery for trauma and emergency services.^5–10

In Rwanda, the Ministry of Health (MOH) established the Service d’Aide Medicale Urgente (SAMU) in 2007 as one of the only publicly run national EMS services in sub-Saharan Africa. In 2014, a simple continuous trauma quality improvement program consisting of five basic clinical metrics was initiated and led to immediate and sustained improvement in all five metrics as well as a composite trauma quality score. If standardized, minimum basic injury care can reliably be provided by the SAMU staff.¹¹ Building on this experience, we hypothesized that developing and implementing protocols and checklists for the most commonly seen emergencies will improve the standardization of prehospital care and the quality of prehospital care delivery in this setting. In this pilot study, we describe the creation of standardized, context-appropriate protocols and checklists for common conditions managed by SAMU and report our preliminary results.

MATERIALS AND METHODS

RESULTS

Forty-two protocols and checklists with associated metrics were developed and implemented in December 2018 across all 60 SAMU staff for use in Kigali, Rwanda. Our original goal of eight was exceeded as there was a request to have protocols for a range of common conditions of the ambulance. These protocols expanded on the current standard for prehospital care in trauma events and addressed a variety of conditions from emergency medical, obstetrics, and pediatrics. Every member of the ambulance service provided input into what they felt was important to be included in each protocol. They all participated in the review of the protocols as they were printed to allow for written comments over several weeks. The protocols were formally presented in a full-day intensive training session prior to the institution of all 42 protocols and checklists. An embedded fellow was present for the first 3 months of their use to provide assistance in the training of the protocols and checklists. The SAMU service has always held daily meetings to debrief on the patients transported over the previous 24 hours. These meetings continued, but a specific emphasis was placed on the understanding and utilization of the eight checklists, chosen as a pilot, in patients who qualified for their use. Since SAMU is a branch of the MOH of Rwanda, this facilitated high-level meetings with their staff. The protocols and checklists were formally presented and approved by the MOH as the standard for SAMU’s prehospital care.

A new ambulance run sheet was developed for SAMU staff to record patient information in the field. The run sheet was designed to capture items in the eight checklists. Additionally, a quality improvement electronic dashboard allowed for run sheets to be electronically recorded and provided real-time metrics for staff to evaluate the care they provide.

To provide additional support to SAMU employees, the “EMS Reference Guide for SAMU Team” (Fig. 1) was created for easy access to checklists while providing services in the field. Included in this reference guide are checklists for the eight most common conditions treated by SAMU, including extremity injury, TBI, AMS, hyperglycemia, hypoglycemia, postpartum hemorrhage, adult acute respiratory distress, and pediatric acute respiratory distress (Fig. 2). All checklists included airway, breathing, circulation (ABC) assessment and universal care, measure of oxygen saturation (SPO2), and administering oxygen if SPO2 %3C;90%, measure systolic blood pressure (SBP) and if SBP <100 place an intravenous (IV), i.e., for adults give a 500-mL bolus and for pediatrics 20 mL/kg bolus, and those appropriate include assess pain and treat according to pain scale ladder: step 1: mild pain (1–3): brufen/diclofenac/paracetamol; step 2: moderate pain (4–6): diclofenac/morphine/pethidine; step 3: severe pain (7–10): morphine/fentanyl/pethidine. Additional checklist items were created to specifically address the treatment for each condition. The reference guide included additional pages such as Glasgow Coma Scale definitions; a faces pain scale (0–10), a modified adult and pediatric pain scale ladder, a burn percentage assessment, a manual for pneumatic tourniquet application, pelvic binder application, and Kendrick binder application. The reference guide also contains the contact numbers for all emergency hospitals located in the four Rwanda provinces as well as Kigali city.

Although our main focus was the creation of the checklists, we report its first month of implementation. In its first month of use, SAMU was dispatched to 539 calls. Fifty-seven percent patients were female (n = 307), with a majority of patients between 18 years and 34 years of age (n = 317). The most common patient type treated was trauma (n = 323), followed by medical (n = 91) and obstetrics and gynaecology (n = 89) (Table 1). Checklists were used for 247 (48.5%) of the 539 calls. The most common patient condition collected within the checklists was extremity injury (n = 164) followed by AMS (n = 27) (Table 2). Checklist evaluation metrics were collected for each condition (Tables 3 to 10). Percentage adherence was highest for the metric administered oxygen when SPO2 <90%, i.e., close to 100% of patients received oxygen when appropriate. The metric with the next highest adherence was assess the ABCs, adherence was between 64% and 100%. All metrics were appropriately treated for patients with hyperglycemia (n = 2) but varied for other checklists (14.3–87.5%). Only two patients had all metrics treated for postpartum hemorrhage, which was later determined to be a supply issue.

DISCUSSION

We collaboratively developed and implemented 42 protocols, 8 of which were piloted for the most common conditions seen by SAMU in Kigali, Rwanda. Our preliminary results are based on a small sample size and short period of implementation; however, they provide evidence that the current model of prehospital training has room for improvement. Our results show that common metrics, such as assessing the ABCs or the administration of oxygen in hypoxic patients, had the greatest adherence; however, condition-specific metrics had lower adherence. These discrepancies in adherence are likely attributed to protocols being new. Additionally, adherence was greater in the more frequent complaints, such as extremity injury and TBI, and lower in those that were less commonly seen, such as hypoglycemia or postpartum hemorrhage. Postpartum hemorrhage had the lowest adherence across all metrics when compared to all other complaints. This could have been because some of the metrics for postpartum hemorrhage were not recorded on previous run sheets and staff were not used to marking it off as an action item on the new run sheet. Several of the metrics that were included in the checklists were not easily measurable (i.e., reduction of a pulseless extremity) or not available on the ambulance (i.e., cardiac monitoring). While these findings may have a variety of explanations from supply chain constraints to novelty of the checklists, our results suggest that standardizing care through the use of protocols will require additional education for condition-specific care moving forward to ensure consistent delivery of high-quality prehospital care.

Globally 45–50% of deaths are preventable with effective emergency care.¹⁵ Therefore, resource-constrained settings must ensure delivery of high-quality care. While standardization of care through protocol and checklist development can improve care delivery, fewer than 1% of existing protocols are directly applicable to LMICs, as most of the data comes from the United States, Europe, and Australia.¹⁶ Developing prehospital protocols may be a time-consuming process, especially as they need to be customized to settings with a wide range of resources in order to be useful.^8,17 Based on discussions with SAMU and evaluation of their existing database, we adapted 42 protocols to become context-appropriate standards for prehospital care in this setting. Some interventions needed to be adjusted due to resource limitations, such as the lack of a cardiac monitor on the ambulances in Rwanda. Several medications needed to be contextualized due to availability in Rwanda, such as the use of salmeterol instead of albuterol for management of respiratory distress. We made changes with expert input from a wide range of fields, which is integral to high-quality protocol development.^16–18 Nevertheless, there were large variations in preliminary adherence to various checklists and within each checklist to each metric being measured which indicate that this process can be used to identify constraints to high-quality care delivery in the prehospital setting in an LMIC.

Our study has inherent limitations. While we assessed adherence to checklists, we did not aim to show changes in clinical outcomes as our focus was on the creation of the protocols and checklists and the month they were introduced. Based on the previous QI program, we expected an immediate improvement in the quality of care provided by SAMU upon implementation of the checklists and new run sheet. While we anticipated that most of the staff would be interested in learning about the motives and internally motivated to meet them, this project did not provide any incentives or disincentives to staff for meeting or not meeting the metrics. This likely contributed to the overall lack of adherence to the checklists during the pilot month. We aimed to engage staff during the metric development process to promote buy-in as this was sufficient and effective for the injury metrics, but this was a much larger project and required much more engagement. We did not include specific variations among each provider in adherence to the protocols/checklists, so it is difficult to determine whether there is a systemic issue in adherence or individual oversight.

Furthermore, this database is a new system, and there is no data entry audit which means that transcription and entry errors may have contributed to low adherence rates. It is unclear whether the focus on measurable metrics affected the rates of completion of metrics that were unmeasured. Lastly, this study may have limited applicability outside Rwanda or outside major metropolitan cities in Africa as resources and political environments vary across settings and affect the quality and efficacy of existing trauma and emergency systems in each setting.

Several challenges were faced during collaboration with the government agencies at a local, regional, and national level. French was the national language of Rwanda until recently, which led to an inherent language barrier between the authors and SAMU staff. The previously used run sheets were written in French and needed to be translated. Additionally, many of the new run sheets were completed in French, which could lead to a loss of information in translation as they were entered into the database by an English speaker.

Owing to our previous work and collaboration with the MOH, and the fact that SAMU was a division of the MOH, we were able to arrange meetings with MOH officials. Multiple drafts of the protocols and checklists were made and revised before everyone agreed and approved the documents. Obtaining approval for implementation of the protocols and checklist was a long and time-consuming process requiring several meetings with the ambulance staff, the director of SAMU and Rwandan MOH. Several inherent barriers existed including the time difference, geographical distance between Rwanda and Virginia, and potential internet connectivity problems when entering data. Having an embedded research fellow in Rwanda dedicated to the project allowed for a more streamlined process.

CONCLUSION

Standardizing treatments of common conditions ensure optimal patient outcomes. The increasing burden of NCDs and injuries in LMICs requires effective trauma and emergency systems to limit needless morbidity and mortality. The literature regarding the development and implementation of protocols for prehospital care in LMICs is limited, but we were able to demonstrate the feasibility of successfully developing and implementing standardized protocols and checklists for prehospital care in Kigali, Rwanda. Further follow-up is in progress to evaluate the consistency of protocol use and checklist adherence over time.

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