Tenwek Hospital

ABSTRACTBackgroundPerioperative morbidity and mortality remain disproportionately high in low‐ and middle‐income countries (LMICs). Quality improvement (QI) has shown effectiveness in improving health outcomes and patient safety across healthcare systems globally and is often a mandatory part of training in high income countries. However, QI education in LMICs remains decentralized and limited in scope. Aiming to address this gap, we designed and delivered perioperative QI education in three LMIC settings. This study aims to summarize methodology and experiences across the three settings and outline the factors leading to success and challenges experienced to inform future QI education efforts in LMICs.MethodsWe designed and implemented a perioperative QI curriculum that included online didactic content, course assessments, and a two to three day in‐person course featuring both didactic and QI project development training. Descriptive statistics were reported for course features and participant pre‐ and post‐course survey results. Qualitative course feedback from participants and administrators is summarized in a narrative format.ResultsFive courses were conducted, training a total of 90 participants. Of those who completed pre‐course surveys, most participants were nurses (35.5%) or residents (43.6%), and the majority (71.1%) had no prior experience with QI. Self‐assessed comfort significantly improved across several domains, including understanding QI concepts, developing aim statements, and designing projects. Qualitatively, participants enjoyed the course's interactive format and recommended future offerings be longer, more frequent, and include expanded content on data analysis and project implementation. Course administrators recommend involving local partners throughout course development, forming structured plans to sustain QI initiatives started as part of the course, and ensuring any pre‐course materials use context‐specific examples.ConclusionImplementation of a perioperative QI curriculum across three LMIC settings was feasible and associated with significant improvements in participant‐reported comfort with core QI skills and knowledge. Success was driven by the inclusion of local faculty, interactive project development, and adaptation of course content to local context. Future efforts should focus on building local QI mentorship capacity, integrating QI education into residency training, and developing contextually appropriate resources to support scalable, sustainable QI training in LMICs.

Rheumatic Heart Disease (RHD), a complication of Beta-Hemolytic Streptococcal infection, is a leading cause of cardiovascular mortality globally, particularly in Sub-Saharan Africa (SSA). While prevention strategies are increasingly emphasized, there is a recognized gap in assessing clinicians’ knowledge, attitude, and practice (KAP) towards RHD prevention, especially in high-burden settings like Kenya. This study aimed to evaluate the KAP of clinicians regarding RHD prevention in Chepalungu, Bomet County, addressing this specific research gap. This was a cross-sectional study involving 98 clinicians from peripheral facilities in Chepalungu, Bomet County, conducted over four months. Data were collected using a questionnaire that assessed demographics, knowledge, attitude, and practice related to RHD prevention. Data analysis involved descriptive statistics (frequencies and proportions), Odds Ratios, and Chi-Square tests to determine associations between variables. Most participants demonstrated good overall knowledge, attitude, and practice concerning RHD prevention. However, critical knowledge gaps were identified in areas vital for patient management. Specifically, only 4% (4 out of 98 participants) had good knowledge of the diagnostic tests for bacterial pharyngitis and the correct duration of antibiotic prophylaxis. A statistically significant relationship was found between knowledge and practice (CI 95%, p=0.024) and between attitude and practice (CI 95%, p=<0.001). The study reveals generally positive attitudes and practices towards Acute Rheumatic Fever (ARF) and RHD management, but also highlights significant knowledge deficits among clinicians. These findings underscore the critical need for continued medical education and ensuring accessible treatment guidelines across all healthcare levels to enhance RHD prevention efforts.

Training and professional development programs for surgeons, anesthetists, obstetricians, and perioperative nurses in low-resource settings are often constrained by lack of access to appropriate training materials. Potential learners looking to access online content are faced with internet connectivity issues, difficulties in finding and accessing resources, resources that are inappropriate for their context and training, and opaque content quality control processes. The United Nations Global Surgery Learning Hub (SURGhub) was launched on June 28, 2023 to address this need. SURGhub curates high-quality surgical, anesthetic, obstetric, and perioperative nursing e-learning courses and makes them freely available on one integrated online platform, optimized for low-bandwidth settings. It is a product of the global surgery community, powered by over 200 volunteers and anchored in the United Nations. In little over 18months since its launch, SURGhub has enrolled 11,451 registered learners from 190 countries. Fifty-five percent of users are based in low- or lower-middle income countries. Learners can access 76 interactive e-learning courses, provided by 20 different institutions. Median course user rating is 4.6/5. SURGhub is addressing the needs of underserved surgical learners through innovative, participatory technological solutions. To address the unmet need, SURGhub must expand its educational offering, including through the addition of new content types, personalized learning, and increased provision of content in languages other than English. The translation of SURGhub educational content into improvements in clinical practice and patient outcomes must be measured.

Machine learning models (MLMs) used to influence surgical decision making often require large and complex datasets upon which to train. However, there is a paucity of literature pertaining to the ability to apply standard MLMs to small ICU datasets within resource-constrained institutions. ML models were applied to a prospective cohort of critically ill mechanically ventilated patients from a teaching hospital in rural Kenya. Characteristics included an ICU scoring system specifically for resource-constrained environments (Tropical Intensive Care Score (TropICS)). Outputs included AUC of the ROC and the feature importance table. Python-based MLMs included XGBoost and KNN. AUC of the ROC was calculated to predict mortality as the primary endpoint. There were 294 patients, with an average age of 40.2years, 64.3% male, 23.8% trauma, and an overall mortality of 60.2%. With respect to mortality patients who died were older (43.5 versus 35years; p < 0.001), but with no difference in male gender (64.8% versus 63.8%; p = 0.9), or having been transferred from outside facilities (34% versus 21.5%; p = 0.5). Whilst there was no difference in the rate of tachycardia or acidosis, patients who died were more likely to present with hemodynamic instability (31% versus 6%; p < 0.001) and higher clinical severity scores. In predicting mortality, the ML models performed very well (XGBoost AUC = 0.82). Within MLM feature importance, the Tropical Intensive Care Score (TropICS) performed as well as APACHE-II and the SAPS. ML models can be effectively applied to a small ICU dataset within resource-constrained environments. ML models must demonstrate functionality prior to incorporating within prospective clinical predictive models. Contextualized ICU scoring systems (TropICS) performed well within MLMs.

Access to diagnostic imaging is significantly limited in much of the world, and sub-Saharan Africa is no exception. Clinician-performed point-of-care ultrasound (POCUS) may provide increased access to diagnostic imaging for many patients in low-resource settings, but training in this modality is limited. We describe the development and implementation of a context-specific, multi-modal pilot POCUS curriculum involving hands-on instruction, in-person and online didactics, asynchronous online image review, and quantitative evaluation. The curriculum was specifically designed for family medicine residents at a rural Kenyan training hospital. This evidence-based training curriculum was designed for integration into a residency curriculum to train Kenyan family medicine physicians to achieve competence in POCUS use and develop the local expertise and leadership necessary to reproduce the training at other institutions. The curriculum was designed specifically for this Kenyan context; however, we provide a detailed description of all curricular elements and review the evidence informing those elements in order to facilitate reproduction at other similar institutions and settings to improve access to POCUS training. We trained eight family medicine resident participants, all of whom strongly agreed with the utility of the curriculum and its component parts. All eight trainees met quantitative competency measures by written evaluations, direct observation, structured clinical exams, image review, and overall numbers of POCUS exams. A total of 1029 ultrasound scans were performed by the participants in the first year of implementation, averaging 128 scans per participant. No participant fully completed the required number of 165 scans for each application; however, most participants are continuing to add to their numbers as planned. Many of these scans were performed under direct faculty supervision to allow for real-time assessment and feedback, and the rest were asynchronously reviewed. All participants also passed all five observed standardized clinical evaluations (OSCEs), demonstrating their competency to perform, record, and interpret images in a timely and accurate manner. We describe many of the logistical requirements and challenges we experienced, as well as our methods of adapting to or overcoming them. Our curriculum is an effective means of developing POCUS competence in an African setting. Our data and experience with implementation may help establish or expand POCUS into medical training in other institutions in sub-Saharan Africa, improving access to this vital diagnostic tool.

BACKGROUNDWide disparities in neurosurgical-oncologic care and treatment outcomes exists globally despite recent improvements in diagnostics and cancer therapy. To better understand the challenges to neurosurgical-oncologic care in low resource settings, we collected data on national neurosurgery capacity and hospital diagnostic and treatment capacity across 7 national referral hospitals in 7 countries Sub-Saharan Africa (SSA).METHODSA 42-item self-administered questionnaire was distributed to partner neurosurgeons at the 7 sites via REDCap in April 2023 to provide country and hospital level capacity data on neurosurgical-oncologic care. RESULTSNeurosurgical and neurosurgical-oncologic care was reported to be available in a limited number of provinces/states/regions in 6 out of the 7 countries. The neurosurgery and pediatric neurosurgery workforce density across the 7 countries ranged between 0.03 – 0.67 per 100,000 and 0 – 0.05 per 100,000 respectively. Three hospitals had no pediatric ICU with the remaining four having between 2-8 bed-capacity pediatric ICU. One hospital did not have both CT and MRI scanner available and relied solely on private diagnostic facilities for neuroimaging. Histopathology services were largely limited to basic hematoxylin and eosin (H&E) and/or advanced histopathology staining. Molecular subtyping was available at only one hospital. None of the 7 hospitals had neurocritical care expertise, neuroradiologist, or neuropathologist. Four hospitals had a pediatric anesthesiologist. Only one hospital had a neuro-oncologist, but none had a pediatric neuro-oncologist. Both adjuvant chemotherapy and radiotherapy was unavailable at 3 hospitals. Rehabilitation was largely limited to basic physical and occupational therapy at all 7 hospitals. Although all 7 countries had a multiple health payer system, the payment structure differed across the 7 hospitals for different neurosurgical-oncologic services with patients making out-of-pocket payments for all services in some cases. Financial constraint was reported as a major barrier to care. CONCLUSIONSystem-level interventions are needed to strengthen neurosurgical-oncologic care capacity in SSA.

Abstract Neurosurgical oncology services (NOS) in Kenya have grown in tandem with resident training programs yet little is known objectively on current capacity and challenges. A 37-item electronic survey was distributed to neurosurgical consultants and residents practicing in Kenya. Among 49 respondents [27 consultants (69% national response rate), 22 residents; median age of 36 – 40; 51% practice &amp;lt; 5 years], 100% and 88% had access to CT scan and MRI brain respectively. 57% performed more than 40 cranial tumor surgeries annually and 48/49 (98%) perform oncology cases on a “regular basis”. Radiotherapy, chemotherapy, and pathology are performed within the respondents’ institutions in 63%, 65% and 61% of surveys, while the rest are sent out. 45 (96%) utilize an operating microscope, and 8 (17%) have an ultrasonic aspirator. Palliative care services are available for 45 (92%). 41 (84%) “agree” or “strongly agree” that delays in referrals between specialties are a major challenge to practice. 38 (78%) “agree” or “strongly agree” that treatment abandonment is also a major challenge. 49% participate in a tumor registry however major barriers to conducting research included lack of funding and protected research time. Having a mentor is perceived as the greatest facilitator for conducting research. No respondents enrolled any patient in a clinical oncology trial during the past year yet nearly every neurosurgeon performs oncology cases and 60% of Kenyan neurosurgeons carry a major tumor case load, in contrast to countries where elective spine surgery predominates neurosurgical practice. Clinical trial enrolment remains uncharted in Kenyan neurosurgery and more than 2/3 of Kenyan counties lack NOS. This survey highlights progress in availability of neurosurgical oncology services while identifying that containing treatment cost, reducing referral delays, and embedding clinical research in clinical practice through mentorship can be NOS growth catalysts.

Survival from pediatric cancers in low-middle-income countries is often very low compared to that of high-income countries due to multifactorial etiologies, including late presentation, delayed diagnosis, difficulty with accessing health care, drug unavailability and treatment abandonment. The St. Jude Pediatric Oncology Facility Integrated Local Evaluation Tool (PrOFILE) was developed to identify the strengths and weaknesses of individual institutions, as well as whole countries. Following the completion of data analysis from Kenyan institutions, the first PrOFILE hybrid in-person and virtual workshop was held. Multi-disciplinary stakeholders prioritized recommendations for improving care and developed smart objectives to accomplish identified goals over the following 2 years. Strengths and weaknesses of conducting a hybrid global workshop were identified.

The conduct of cardiopulmonary bypass in neonatal, infant, and pediatric patients continuously evolves as new devices and innovative techniques are introduced. Since 1989, periodic pediatric perfusion surveys have been conducted to ascertain practice patterns involving demographics, equipment, and perfusion techniques. The goal of this current project is to provide an updated perspective on international pediatric and congenital perfusion practice since the last survey conducted in 2016. In July 2021, a 100-question perfusion survey was distributed to 284 pediatric cardiac surgery centers using a secure web browser-based data application. Each center was given a unique survey hyperlink to ensure one response per institution and to monitor the response rate. Centers were given 1 month to complete the survey and electronic reminders were sent weekly to nonrespondents. After the survey was closed, information from completed surveys was exported to a software program for analysis. Responses were received from 153 of 284 pediatric centers for a response rate of 54%. Sixty respondents (39%) were from North American (NA) centers while 93 respondents (61%) were from non-North American (NNA) centers. The vast majority of centers use a roller head arterial pump (93%), hollow fiber oxygenators with open reservoirs (86%), and integrated arterial line filters (73%). The use of modified ultrafiltration was reported by 76% of centers. Ninety-two percent of centers reported the use of selective antegrade cerebral perfusion for aortic arch repairs. The N + 1 staffing model was most prevalent (52%), followed by two perfusionists per case (33%). Periodic surveys continue to be a useful modality in assessing regional variation in pediatric perfusion practice. This survey marked the first time the majority of responses came from non-North American institutions. Identifying these practice patterns may aid in the development of, and adherence to, regional standards and guidelines. This would foster the reduction of variation in practice and potentially improve patient safety.

Risk stratification algorithms (RSAs) can reduce antibiotic duration (AD) and length of stay (LOS) for early-onset sepsis (EOS). Because of higher EOS and antibiotic resistance rates and limited laboratory capacity, RSA implementation may benefit low- and middle-income countries (LMIC). Our objective was to compare the impact of 4 RSAs on AD and LOS in an LMIC nursery. Neonates <5 days of age admitted for presumed sepsis to a Kenyan referral hospital in 2019 (n = 262) were evaluated by using 4 RSAs, including the current local sepsis protocol ("local RSA"), a simplified local protocol ("simple RSA"), an existing categorical RSA that uses infant clinical examination and maternal risk factors (CE-M RSA) clinical assessment, and the World Health Organization's Integrated Management of Childhood Illness guideline. For each RSA, a neonate was classified as at high, moderate, or low EOS risk. We used к coefficients to evaluate the agreement between RSAs and McNemar's test for the direction of disagreement. We used the Wilcoxon rank test for differences in observed and predicted median AD and LOS. Local and simple RSAs overestimated EOS risk compared with CE-M RSA and the Integrated Management of Childhood Illness guideline. Compared with the observed value, CE-M RSA shortened AD by 2 days and simple RSA lengthened AD by 2 days. LOS was shortened by 4 days by using CE-M RSA and by 2 days by using the local RSA. The local RSA overestimated EOS risk compared with CE-M RSA. If implemented fully, the local RSA may reduce LOS. Future studies will evaluate the prospective use of RSAs in LMICs with other interventions such as observation off antibiotics, biomarkers, and bundled implementation.