R. G. Maine1,2,3,4, C. Habiyakare10, T. Nkurunziza5, A. Hategekimana8, P. Mizero8, W. Ndayambaje5, E. Nsengiyumva6, J. Havugimana6, J. Nigilimana9, J. Uwimungu5, J. Meara2,3, G. Ntakiyiruta6,7, J. Mubiligi5,9, R. Riviello1,2,7 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 3Boston Children’s Hospital,Plastic And Oral Surgery,Boston, MA, USA 4University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 5Inshuti Mu Buzima (Partners In Health),Kigali, , Rwanda 6University Of Rwanda,School Of Medicine,Kigali, , Rwanda 7Central Teaching Hospital Of Kigali,Department Of Surgery,Kigali, , Rwanda 8Rwinkwavu Hospital,Kayonza, , Rwanda 9Butaro Hospital,Burera, , Rwanda 10Kirehe Hospital,Kirehe, , Rwanda
Introduction:
Many countries have few surgeons and patients who need surgical care must transfer to the hospitals where those surgeons work. Few studies have evaluated the surgical transfer system in these low resource settings to understand indication for transfer and patient outcomes after transfer. This study evaluated surgical transfers at three district hospitals in Rwanda.
Methods:
We retrospectively reviewed the charts of all patients admitted to the surgical ward at these hospitals in Rwanda from January 1, 2013 to December 31, 2013. We also reviewed charts of patient who transferred from other wards to the referral center for surgical care. At the district hospitals, diagnosis, surgical treatment, and indication for transfer were collected. At the referral center treatment received and complications were collected. Complications included death, surgical site infections, pneumonia, urinary tract infection, pressure ulcers, unplanned reoperation or intubation, anastomotic leak, and other infections.
Results:
A total of 2139 surgical ward charts were reviewed at the district hospitals. An additional 299 charts of patients who transferred from other wards were reviewed. Of all surgical ward admissions, 353 (16.5%, 95%CI:14.9%-18.1%) were recommended to transfer, and 256 (72%, 95%CI:67.5%-77.1%) transferred. The percent of patient who transferred from the surgical wards at the district hospitals were 10.2%, 17.9% and 10% (p<0.001). A diagnosis was documented in 521 patients who transferred from all wards. The primary diagnoses for transferred patients include: fractures 140 (27.3%), other trauma 76 (14.8%), cancer 67 (13.1%), and surgical infections 47 (9.2%). The indications for transfer included lack of appropriate personnel at the district hospital 82.1%, lack of equipment 27.3%, lack of supplies 2.7%, need for intensive care 5.3%, patient or family preference 1.4%, or development of a complication at the district hospital 0.7%. The remaining 4.2% of patients transferred for an unknown reason.
A total of 399 records were located at the referral hospital. Of the records located, 236 (59.1%, 95%CI:54.1-64%) patients received an operation at the referral hospital. This compares to 62.8%, 13.4% and 13.9% of patient admitted to the surgical ward at the three district hospitals (p <0.001). The overall complication rate for surgical ward patients at the district hospitals was 4.65: 5.7% for transferred patients and 4.4% for non-transferred patients(p =0.35). At the referral hospital, 66 patients(16.5%, 95%CI:13%-20.6%) developed a complication.
Conclusion:
Transfers for surgical care are common in district hospitals in Rwanda. The primary reason for transfer is the appropriate expertise is not available at the district hospital. Injuries are the most common diagnosis for transferred patients. Complications are common for these patients. Evaluation of skill sets of district hospital personnel and delays in surgical care for transferred patients is needed.