Thursday, April 27, 2017

MHealth at a District Hospital in Rural Rwanda

Kristin Ojomo MD
Arthur Tracy Cabot Research Fellow / Henry Ellis Warren Fellow
Center for Surgery and Public Health
Brigham and Women’s Hospital

MHealth at a District Hospital in Rural Rwanda

Surgical site infections (SSI) are a significant cause of morbidity and mortality worldwide, and particularly in low- and middle-income countries, where geographic and infrastructural barriers often delay or prevent post-operative patients from returning to care. In these settings, rates of SSI can reach 30%. In Rwanda, the current standard of care does not include follow-up of post-operative surgical patients. There, a network of community health workers (CHWs) are employed to provide care and follow-up for pregnant and post-partum women as well as children under five years of age. However, the limited education and existing work load of these workers preclude them from supporting the follow-up of other specialized conditions, such as post-operative patients.

Funded by a R21, and under the direction of Dr. Robert Riviello MD, and Bethany Hedt-Gauthier PhD (co-PIs)  I recently traveled to Rwanda as the study coordinator for a randomized control trial evaluating the utilization of CHWs in the surgical realm. The first aim of the study is to optimize a screening protocol to identify SSI in patients receiving surgery at Kirehe District Hospital (KDH) post operatively. This initial phase involves screening 450 patients first by a general practitioner and then by a surgical CHW (sCHW) using a six-question protocol (on a table using a mobile application). The second aim is to evaluate the impact of the SSI screening protocol, delivered by sCHWs on the rate of return to care for patients with SSI 10 days post-operation. Two CHW-mHealth interventions will be evaluated. In the first, a sCHW will visit post-operative study participants in their homes to administer the screening protocol prompted by the mobile phone. In the second, a sCHW will call the patient and administer the same screening protocol over the phone. In this phase of the research, 400 patients will be assigned to each of these delivery arms, and the rates of appropriate return to care will be compared to that of 400 patients in a control arm receiving the standard of care (i.e. no additional follow-up).

During this first trip, my goal was to help organize and start Phase 1 of the study.  Along with 2 data collectors and a study coordinator, we traveled to Kirehe Hospital, located approximately 3 hours from Kigali.  Kirehe is a District Hospital with 120 beds, 2 operating rooms, 1 Ob-gynecologists, and 12 general practitioners. The hospital performs almost exclusively c-sections (close to 1200/year).  We were warmly welcomed by the hospital staff who were excited about the potential for this clinical research to improve surgical care.  We were able hire a CHW who we trained for 2 weeks prior to the initiation of our study. Our first day of enrollment was March 20th and we had a very successful day enrolling over 9 patients. To date, we have now enrolled close to 90 patients and our CHW has already started to correctly diagnose surgical site infections.  We plan to continue this phase until the end of August, prior to initiation of randomization. 
Study Staff: Theo (study coordinator), Kristin (study coordinator), Bahati (data collector), Leni (data analyst), Edison (data collector)

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