How Rwanda's new Emergency Medicine team reduced mortality rates from 6% to 1%

This year Rwanda will be hosting Africa's Conference on Emergency Medicine. With the recent steep gains they've made it's an ideal country for the conference to be based in. This short blog will outline some of the developments specifically in emergency medicine in the country.

Before EM in Kigali

Around four years ago emergency medicine didn't exist as a separate specialty in Rwanda. On a walk around of the hospital I saw the old Emergency Department (ED) where during crowding episodes less urgent patients would sit outside on the grass or on mattresses on the floor in order to create more capacity. Reflecting on the ED unit in those days Dr Gabin Mbanjumucyo, President of the Rwandan Emergency Care Association, said:

"ED used to be just like a ward, we never had consultants, it was run by doctors with one year post-graduate experience. You'd come into the ED and get diagnosed, treated, you'd get everything there, then go home."

Dr Gabin Mbanjumucyo, speaking in front of CHUK ED

The ED worked as another ward run by generalists rather than specialists in emergency medicine (EM). As a result, mortality during these times was around 6%. Recognising the increasing importance of EM, the hospital built a dedicated ED unit increasing its size and improving its design. But there was still a need for a medical team with specialised EM training.

Rwanda's first generation of EM Consultants

In 2013 Rwanda had its first intake of specialty trainees in emergency medicine thanks to the largely US funded Human Resources for Health (HRH) programme. HRH introduced a two-tier training programme to up-skill Rwanda in emergency medicine. The first two years post-graduate training were across all district hospitals to increase general EM skills across the country. This was then followed by three years' further study for 12 trainees to gain a Masters of Medicine in EM (Mbanjumucyo et al, 2015). A combination of US, Canadian and UK doctors were resident in Rwanda as faculty to teach trainees and trainers both in the capital and across district hospitals. 

This year has seen the first generation of these new ED Consultants graduate - a huge milestone.  Despite being new ED Consultants, graduates have already taken on leadership roles alongside their clinical commitments and are now leading the training of future generations of ED Consultants in the country - next year will see a further eight graduate.

The impact of the move from the generalist model to the new ED specialist-led department has been dramatic. Processes have been standardised and implemented including protocols for certain presentations and standardised approaches to triage. Following the introduction of the new Emergency Medicine Consultant-led ED, the effect on mortality has been dramatic: dropping from 6.3% to 1.2% within one year. 

Mortality rates in ED and across CHUK before and after introducing newly trained EM team. Data provided by Gabin Mbanjumucyo and published in Aluisio, A. R. et al (2017)

Public health interventions

Alongside the dramatic improvements in ED processes and outcomes, it is worth mentioning the proactive public health approach to reducing trauma deaths in Rwanda. Road Traffic Injuries are a major driver of trauma in ED accounting for over 70% of presentations (Mbanjumucyo et al, 2016). Of these 70%, mass casualties used to occur frequently due to cars and lorries attempting to speed around the hillsides of Rwanda. Those in the department talked of frequently seeing 20-30 casualties presenting from these multi-vehicle collisions - indeed there are protocols and rooms for matresses to be laid out to treat such high patient numbers. However in the face of this epidemic, the government introduced initially unpopular reductions to speed limits. They fell to 40kmh in cities and 60kmh outside - a drop of 20kmh. As a result of this, there hasn't been a single mass casualty event this year. The government move to improve mortality rates despite it requiring initially unpopular decisions was striking. 

Similarly, a high proportion of trauma (51.4%) are due to motorbike accidents - motos are the most common means of transport across Rwanda and also act as taxis.  The government has also been quick to act on these kinds of risks - in Rwanda it is a legal requirement for all motorbike riders and passengers to wear a helmet. Surprisingly, the law is strictly adhered to, unlike other countries I've visited. Despite this, motorbikes continue to be a key cause of ED trauma - particularly lower leg trauma - so further work is needed.

The future

As you can see, the progress in the last few years in emergency medicine in Rwanda is striking and very positive. Despite this, the team there are keen to further develop the department and specialty. An active research hub, projects are underway to review and publish further results on mortality and trauma care in Rwanda. The change in culture in ED is now spreading across the hospital. For example, a key challenge for ED is that ventilated patients frequently get stuck in resus  for a week or more often with poor outcomes. In the face of this, there is a recognised need to improve ICU capacity and training as well as speed up flow across the hospital. Dr Menelas Nkeshimana, Head of Medicine and Emergency Medicine, said of the future of the department's journey:

"We need to spread professional standards and consistency across the hospital. We need to ensure people don't accept poor standards and we continue to improve quality of care."

Dr Menelas, Consultant Physician and Head of EM and Internal Medicine

It will be fascinating to watch this new team grow and develop EM across Rwanda from this very positive foundation.

Articles referenced

Aluisio, A. R. et al (2017), Impact of Implementation of Emergency Medicine Training on Emergency Department Mortality in Kigali, Rwanda: An Interrupted Time-Series Quasi-Experimental Design, Annals of Emergency Medicine, Vol 70 no. 4s.

Mbanjumucyo, G. et al (2015), State of emergency medicine in Rwanda 2015: an innovative trainee and trainer model. International Journal of Emergency Medicine, 8:20.

Mbanjumucyo, G. et al (2016), Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda, African Journal of Emergency Medicine, 6:191-197.