Mass Casualty Response in a Low-Resource Context : Challenges and Opportunities in Rwanda’s Mass Casualty Incident Response
Background In a mass casualty incident (MCI), sudden patient surges can overburden the health system and cause material and human resource limitations, as well as challenges in adapting systems and structures to the changed needs. This leads to an increased risk of avoidable patient morbidity and mortality. Low-resource countries bear the brunt of the global trauma and disaster burden, and, although not formally assessed, are more likely to be more frequently exposed to MCIs. The ability to adequately manage a sudden patient influx is called “surge capacity”, and can be measured using the 4S-Framework, which assesses the dimensions staff, stuff, systems, and space. However, current MCI research primarily originates from high-resource settings, with uncertain generalizability to low-resource settings. Objectives This thesis aimed to increase the understanding of MCI epidemiology in Rwanda, including at the incident level (event type, location, and timing) and at the patient level (injury patterns, patient outcomes, treatment provided) (studies I and IV). Secondly, this thesis aimed to assess the surge capacity to manage mass casualty incidents in Rwanda (studies II, III, and IV), and to develop a knowledge base for future surge capacity strengthening efforts. Materials and Methods This thesis employed multiple study designs and analysis methods. Study I was a pilot study for a new data collection method (the media review), based on a scoping review methodology using a database of news items. Study II was a qualitative study with semi-structured interviews with trauma care responders, which were analyzed using qualitative content analysis. Study III was a cross-sectional survey study of surge capacity perceptions with clinical department leaders at Rwanda’s leading trauma hospitals. Study IV was a retrospective study of routine prehospital data from emergency medical services (EMS). Studies I, III, and IV utilized descriptive statistics and parametric and non-parametric hypothesis tests for group comparisons. Study III additionally utilized analysis of one-way variance to assess intra-class correlation between respondents from the same hospital, and study IV utilized mixed-model analysis based on logistic and linear regression to evaluate the role of confounders in EMS MCI dispatch. Main results Studying MCIs and surge capacity in Rwanda is challenged by the lack of appropriate registers, the sudden onset of events, and resource limitations. In Rwanda, the media review demonstrated extensive reporting on the number of injured victims, on-site deaths, and the geographic location of the MCI, indicating that this method can be used as a complementary method to assess epidemiological patterns in MCIs in the absence of trauma registers. Rwanda has a high MCI exposure, with road-traffic accidents being the most frequent, but natural hazards appear to be on the rise. The majority of mass casualty incidents are small to moderately sized. MCIs are managed at all levels of the health system. Perceived surge capacity to manage low- to moderately sized mass casualty incidents is high in Rwanda. Trauma care responders attribute this to the wealth of real-life experience in MCI management and having a supportive team. The successful resolution of dilemmas during MCIs can lead to positive effects such as self-confidence, teambuilding, and personal or professional growth. Surge capacity is higher in tertiary “level 1” hospitals, located in urban areas. There are specific challenges in the Rwandan context, primarily resource and staff shortages, as well as limited EMS coverage in rural areas, that limit the generalizability of surge capacity paradigms from high-income countries. In formal assessment, surge capacity is limited in all 4S-domains metrics, including low levels of disaster plan uptake and limited awareness of existing plans. Formal surge capacity routines are also limited in the pre-hospital setting. Yet, Rwandan trauma care workers and emergency medical services utilize surge capacity strategies, including patient distribution to multiple facilities, on-site patient EMS treatment to reduce hospital referrals, and patient co-transportation. However, MCIs in rural areas are less likely to be managed by formal EMS. Viewed in the light of limited in-hospital surge capacity in rural areas, rural patients are likely at higher risk of poor outcomes in mass casualty incidents in Rwanda. Conclusions Despite limited formal disaster planning and routines, Rwanda appears to have developed a strong surge capacity to manage small- to moderately sized mass casualty incidents organically. However, there are limitations to surge capacity and areas for improvement in all 4S-domains, including staff, stuff, systems, and space, especially in rural areas. Trauma systems and emergency medical services need further development to ensure adequate surge capacity.
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