Using the World Society of Emergency Surgery (WSES) Triage Tool to Evaluate Timing of Emergency Surgery in Rwanda

Abstract

Background: Access to timely and safe emergency general surgery remains a challenge in sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study has the following objectives: (1) to compare the actual time to surgery (aTTS) to the ideal time to surgery among patients undergoing emergency surgery and (2) to explore the use of home to emergency department time (HET) as a new measurement indicator for time from symptoms onset to admission at ED at a referral hospital.

Methods: We performed a retrospective review of emergency general surgery cases performed at the Centre Hospitalier Universitaire de Kigali in Rwanda between June 1 and November 31, 2016. Our primary outcomes included actual time to surgery (aTTS) in hours (defined as time from admission at ED to induction of anesthesia) and actual home to emergency department (ED) time (aHET) in days (defined as time from onset of symptoms to admission at ED). Our secondary outcome was the overall in-hospital mortality rate.

Results: During the study period, 148 emergency surgeries were performed. Most of the patients were male (80%), aged between 15 and 65 (69%), from outside Kigali (72%), and with insurance (80%). The most common diagnosis was abdominal trauma (24%), followed by peritonitis (20%), and intestinal obstruction (16%). The median aTTS was 7.8 h, and the median aHET was 2.43 days. Most patients (77%) experienced delays in timely surgery after admission to ED, and aTTS was 15.5 h for Fournier's gangrene, 10.8 h for abdominal trauma, 11.3 h for appendicitis, 10.5 h for intestinal obstructions, and 12.3 h for peritonitis. Likewise, most patients (52%) experienced delays in reaching the ED, especially those with appendicitis (15.2 days), peritonitis (8.5 days), testicular torsion (7.2 days), Fournier's gangrene (5 days), and intestinal obstruction (3.7 days). The case fatality rate by diagnosis was highest for polytrauma (100%) and peritonitis (60%); the overall in-hospital mortality rate was 23%. Some of the poor outcomes associated with in-hospital delay include reoperation and death. Factors to consider in triage for referral include age, diagnosis, and high risk of death.

Conclusion: Our study found that the median aTTS was 7.8 h and most patients (77%) were delayed in having timely surgery after admission at ED. In addition, the median aHET was 2.5 days and most patients (52%) were delayed in reaching the ED. Improving processes to facilitate access and to perform timely emergency surgery through the referral system has a potential to decrease delay and improve outcomes.