Infectious Outcomes Assessment for Health System Strengthening in Low-resource Settings: The Novel Use of a Trauma Registry in Rwanda

Abstract

Background: More than 90% of injury deaths occur in low-income countries where a shortage of personnel, infrastructure, and materials challenge health system strengthening efforts. Trauma registries developed regionally have been used previously for injury surveillance in resource-limited settings, but scant outcomes data exist. Methods: A 31-item, two-page registry form was developed for use in Rwanda, East Africa. Data were collected over a one-year period from April 2011 to April 2012 at two university referral hospitals. Inpatient 30-d follow up data were abstracted from patient charts, ward reports, and operating room logs. Complications tracked included surgical site infection (SSI), pneumonia, urinary tract infection (UTI), decubitus ulcers, transfusion, cardiac arrest, respiratory failure, and blood thromboses. Univariate analysis with chi-square and the Fisher exact test was performed to determine the association between complications and hospital stay and complications and mortality. Multivariable logistic regression was used to control for age, gender, hospital, mechanism of injury (penetrating versus blunt), and Glasgow Coma scale score (GCS). Results: A total of 2,227 patients were recorded prospectively. One thousand five hundred nineteen patients were admitted for inpatient care (69%) with a 4% (n = 67) 30-d mortality. One hundred thirteen patients developed a hospital-acquired infection (88 SSI, 15 UTI, 12 pneumonia). For admitted patients, 25% (n = 387) were still in-hospital at 30-d. Whereas the development of any complication was associated with an increased mortality (p < 0.0001, unadjusted OR 3.2, 95% CI 1.8–5.7), there was no association between the development of an infection and mortality (p = 0.6). Hospital-acquired infection was associated with an increased length of stay (p < 0.0001, adjusted odds ratio (OR) 7.3, 95% confidence interval (CI) 4.7–11.2). Surgical site infection and UTI were individually associated with an increased length of stay. Conclusions: The development of hospital-acquired infections is associated with an increased hospital stay in the trauma population in Rwanda. This has important implications in improving a health system already strained by limited infrastructure, personnel, and finances.