Defining the Three Delays in Referral of Surgical Emergencies from District Hospitals to University Teaching Hospital of Kigali, Rwanda

Abstract

Background Surgical conditions represent up to 30% of the global burden of diseases. The aim of this study was to assess the delays in patients transferred to a tertiary referral hospital from district hospitals (DHs) in Rwanda with emergency general surgery (EGS) conditions. Methods We performed a prospective review of all EGS patients referred from DH over a 3-month period to assess delays in transfer and accessing care. We then surveyed general practitioners to define their perspective on delays in surgical care. Results Over a 3-month period, there were 86 patients transferred from DH with EGS conditions. The most common diagnoses were bowel obstruction (n = 22, 26%) and trauma (n = 19, 22%). The most common performed operations were laparotomy (n = 21, 24%) and bowel resection (n = 20, 23%). The mortality rate was 12%, and the intensive care unit admission rate was 4%. In transfer to the referral hospital, 5% patients were delayed for financial reasons and 2% due to lack of insurance. After reaching CHUK, 5% patients were delayed due to laboratory and radiology issues. Other delays included no operating theater available (4%) and no surgeon available (1%). Providers' perceptions for not performing surgeries at DH were predominantly the lack of a competent surgical provider or anesthesia staff. Conclusion EGS patients represent a broad range of diagnoses. Delays were noted at each step in the referral process with multiple areas for potential improvement. Expanding surgical access at the DH has the potential to decrease delays and thereby improves patient outcomes.

Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi‐disciplinary Stakeholder Exercise

“…Injury: Mpirimbanyi et al [ 24 ], Petroze et al [ 21 ], Calland et al [ 40 ], Nkusi et al [ 43 ], Lashoher et al [ 22 ]…”

“…Injury: Mpirimbanyi et al [ 24 ], Calland et al [ 40 ], Chokotho et al [ 39 ], Ntakiyiruta et al [ 44 ]…”

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

“… 25 As this review excluded studies not specifically focusing on injuries, other approaches may have been missed, particularly in areas that were not well covered such as Delay 1. 226 Methods in this review overlapped conceptual delays, particularly across the Delay 2 and 3 categories. Finally, we have not clearly characterised the relative amount of focus on each delay for each study, although in many cases the facility-based focus predominated.…”

Development of an acute care surgery service in Rwanda

“…In addition, many patients present in a delayed fashion which increases the risk of advanced, complex disease. Studies have shown that the greatest delay is in the prehospital time period which is not addressed by implementation of the ACS service 16…”