Title: Rwanda912: Use of an innovative electronic communications platform to improve pre-hospital transport of injured people in Rwanda.
Funder: Department of Health and Social Care

Abstract: Research question Can a novel electronic system, Rwanda912, which uses an ambulance Destination Decision Support Algorithm (DDSA), improve transport time of injured patients to a facility that can treat them, in two areas (urban-Kigali and rural-Musanze), in Rwanda? Background In Rwanda, injury causes substantial disability and 9% of all deaths, 47% of which occur before-hospital. Many of these injury-related deaths and disabilities would be avoidable if delays getting to hospital were reduced. Rwanda has a country-wide free ambulance system. However, inefficiencies in communication and coordination between the ambulance and facilities cause delays in getting the right patient to the right hospital at the right time. In this multidisciplinary project, involving academics, the Ministry of Health (see letter from The Honourable Minister of Health), ambulance services, and a local not-for-profit software company (Rwanda Build Program [RWBuild]), we propose to test the efficacy and implementation of a novel, award winning, electronic system, Rwanda912, to reduce delays in transport to hospital for injured patients. Methods Our primary effectiveness outcome is time from injury to arrival at an appropriate facility. Secondary outcomes are clinical or process (e.g. death, need for ITU, length of stay). We will use an Interrupted Time Series (ITS) approach to assess effectiveness of the intervention &ndash; Rwanda912. ITS is known to be a robust method to assess effectiveness in real-world situations where a randomised controlled trial cannot be done. We will study implementation outcomes using the RE-AIM QuEST framework, which combines qualitative and quantitative measures to understand the intervention s Reach, Effectiveness, Adoption, Implementation, and Maintenance. These outcomes will facilitate understanding of the reasons for the primary and secondary effectiveness outcomes and aid in the transferability of findings elsewhere. Costs, resource use, and cost-consequences will be captured. Timelines for Delivery The project will run for 56 months. The first 3 months are for set-up. Pre-intervention data collection will be complete in months 27 and 39 in Kigali and Musanze, respectively; post-intervention data collection will be complete by months 48 and 50 in Kigali and Musanze, respectively. Rwanda912 development will be finalised whilst pre-intervention data are collected. Dissemination will be ongoing, but maximal in the final 9 months. Capacity Building is central to our project; the research capacity building plan has been developed after a capacity building survey was done with partners in Rwanda. This project will also support local technical capacity building; a key theme of RWBuild. The study question was developed after extensive community and stakeholder engagement; this will continue throughout delivery and dissemination of the study, ensuring its translation to policy. Impact will come from improved patient outcomes and research capacity in Rwanda, as well as transferability to other LMICs, if successful. Involvement of multiple stakeholders will contribute to the impact of the study, ensuring that the study is delivered and disseminated in a contextually appropriate manner. Our extensive networks with policy organisations (like WHO) and regional trauma organisations, will facilitate uptake of the intervention elsewhere. Our far-reaching dissemination plan to lay-people, academics, and policy makers will ensure impact.

Lay abstract: Delays in getting injured patients to hospital in a timely manner result in avoidable death and disability. This is particularly the case in low- or middle-income countries (LMICs), where even when ambulance systems are available, communication between ambulance systems, patients, and hospitals is inefficient. In Rwanda, injury causes 9% of deaths; 47% occurring before-hospital. Similar to many LMICs, Rwanda experiences long delays in getting patients to hospital, with all communication between patients, ambulances, and hospitals done using multiple phone-calls. To overcome these difficulties, a local software firm designed Rwanda912, a novel electronic tool for use in low resource settings. Rwanda912 uses an ambulance Destination Decision Support Algorithm (DDSA) which regularly collects information from hospitals on availability of staff and equipment, and from the ambulance crew on patient status; it uses this information to match the patient with the nearest able hospital. It has been endorsed by the Rwandan Ministry of Health (MoH) and won local innovation awards. In collaboration with MoH, Rwandan ambulance services, and local and international academics, this project will test whether Rwanda912 reduces time from injury to arrival at hospital and improves clinical outcomes such as death and length of stay in hospital. We will ensure Rwanda912 is acceptable to users and failsafe in the field before deploying it in ambulances and testing whether it improves patient outcomes in a major urban and rural district in Rwanda. As well as collecting information on patient outcomes after Rwanda912 is deployed, we will collect information from people who use Rwanda912 about its &ldquo;user friendliness&rdquo; and whether it is being used as intended. Additionally, we will assess the costs and resources needed to develop and deploy it. These outcomes will be used to determine roll-out throughout the country by MoH and provide knowledge to enable its transferability to other countries. Our study focusses on injured patients, however, if successful, the findings will apply to other emergency conditions requiring ambulance transport. Capacity building is central to the project, supporting development of project management, research, and software development skills amongst Rwandan partners. The project will also support Rwandan PhD students to be joint supervised by Rwandan and UK supervisors. The project development has been informed through deep engagement with key stakeholders - including patients, healthcare workers, and policy makers - on their needs and priorities around injury care. Stakeholder engagement will continue throughout the project, in project management, governance, and ensuring that the research findings have impact. We plan to achieve this through a structured program, supporting and enabling community and health systems stakeholders to drive policy based on the research findings. Engagement with our international collaborators including at WHO and Emergency Medical Societies in LMICs will ensure maximal international impact.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: INJURIES AND ACCIDENTS