Defining the Three Delays in Referral of Surgical Emergencies from District Hospitals to University Teaching Hospital of Kigali, Rwanda

  • Christophe MpirimbanyiEmail author
  • Egide Abahuje
  • Aime Dieudone Hirwa
  • Miguel Gasakure
  • Elisee Rwagahirima
  • Christian Niyonzima
  • Adolphe Niyoyita Hakizimana
  • Epiphanie Ishimwe
  • Faustin Ntirenganya
  • Jennifer Rickard
Surgery in Low and Middle Income Countries



Surgical conditions represent up to 30% of the global burden of diseases. The aim of this study was to assess the delays in patients transferred to a tertiary referral hospital from district hospitals (DHs) in Rwanda with emergency general surgery (EGS) conditions.


We performed a prospective review of all EGS patients referred from DH over a 3-month period to assess delays in transfer and accessing care. We then surveyed general practitioners to define their perspective on delays in surgical care.


Over a 3-month period, there were 86 patients transferred from DH with EGS conditions. The most common diagnoses were bowel obstruction (n = 22, 26%) and trauma (n = 19, 22%). The most common performed operations were laparotomy (n = 21, 24%) and bowel resection (n = 20, 23%). The mortality rate was 12%, and the intensive care unit admission rate was 4%. In transfer to the referral hospital, 5% patients were delayed for financial reasons and 2% due to lack of insurance. After reaching CHUK, 5% patients were delayed due to laboratory and radiology issues. Other delays included no operating theater available (4%) and no surgeon available (1%). Providers’ perceptions for not performing surgeries at DH were predominantly the lack of a competent surgical provider or anesthesia staff.


EGS patients represent a broad range of diagnoses. Delays were noted at each step in the referral process with multiple areas for potential improvement. Expanding surgical access at the DH has the potential to decrease delays and thereby improves patient outcomes.


Compliance with ethical standards

Conflict of interest

The authors have no financial disclosures to report.


  1. 1.
    McCord C, Ozgediz D, Beard JH et al (2015) General surgical emergencies. In: Debas HT, Donkor P, Gawande A et al (eds) Essential surgery: disease control priorities, vol 1, 3rd edn. World Bank, WashingtonGoogle Scholar
  2. 2.
    Petroze RT, Nzayisenga A, Rusanganwa V et al (2012) Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 99:436–443CrossRefGoogle Scholar
  3. 3.
    Linden AF, Maine R, Hedt-Gauthier BL et al (2015) Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey. Lancet 385(Suppl 2):S9CrossRefGoogle Scholar
  4. 4.
    Linden AF, Maine RG, Hedt-Gauthier BL et al (2016) Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda. Surgery 159:1217–1226CrossRefGoogle Scholar
  5. 5.
    Wong EG, Ntakiyiruta G, Rousseau MC et al (2015) Acute care surgery in Rwanda: operative epidemiology and geographic variations in access to care. Surgery 158:37–43CrossRefGoogle Scholar
  6. 6.
    Ibrahim NA, Oludara MA, Ajani A et al (2015) Non-trauma surgical emergencies in adults: spectrum, challenges and outcome of care. Ann Med Surg (Lond) 4:325–330CrossRefGoogle Scholar
  7. 7.
    Khan S, Zafar H, Zafar SN et al (2014) Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes. World J Surg 38:281–286. CrossRefGoogle Scholar
  8. 8.
    Forrester JD, Forrester JA, Kamara TB et al (2016) Self-reported determinants of access to surgical care in 3 developing countries. JAMA Surg 151:257–263CrossRefGoogle Scholar
  9. 9.
    Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med 38:1091–1110CrossRefGoogle Scholar
  10. 10.
    Pilkington M, Situma M, Winthrop A et al (2018) Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara Regional Referral Hospital, Uganda. J Pediatr Surg 53:1073–1079CrossRefGoogle Scholar
  11. 11.
    Niyitegeka J, Nshimirimana G, Silverstein A et al (2017) Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda. BMC Pregnancy Childbirth 17:242CrossRefGoogle Scholar
  12. 12.
    Nkurunziza T, Toma G, Odhiambo J et al (2016) Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Surgery 160:1636–1644CrossRefGoogle Scholar
  13. 13.
    (2015) Rwanda demographic and health survey, 2014–15. In: Rwanda NIoSo (ed). NISR, MOH, ICF International, Rockville, Maryland, USAGoogle Scholar
  14. 14.
    Muhirwa E, Habiyakare C, Hedt-Gauthier BL et al (2016) Non-obstetric surgical care at three rural district hospitals in rwanda: more human capacity and surgical equipment may increase operative care. World J Surg 40:2109–2116. CrossRefGoogle Scholar
  15. 15.
    Rickard JL, Ntakiyiruta G, Chu KM (2015) Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital. J Surg Educ 72:e73–e81CrossRefGoogle Scholar
  16. 16.
    Rickard JL, Ntakiyiruta G, Chu KM (2016) Associations with perioperative mortality rate at a major referral hospital in Rwanda. World J Surg 40:784–790. CrossRefGoogle Scholar
  17. 17.
    Meara JG, Leather AJ, Hagander L et al (2015) Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569–624CrossRefGoogle Scholar
  18. 18.
    Galukande M, von Schreeb J, Wladis A et al (2010) Essential surgery at the district hospital: a retrospective descriptive analysis in three African countries. PLoS Med 7:e1000243CrossRefGoogle Scholar
  19. 19.
    Faine BA, Noack JM, Wong T et al (2015) Interhospital transfer delays appropriate treatment for patients with severe sepsis and septic shock: a retrospective cohort study. Crit Care Med 43:2589–2596CrossRefGoogle Scholar
  20. 20.
    Wu D, Zhou X, Ye L et al (2015) Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock. Acad Emerg Med 22:915–921CrossRefGoogle Scholar
  21. 21.
    Binagwaho A, Kyamanywa P, Farmer PE et al (2013) The human resources for health program in Rwanda–new partnership. N Engl J Med 369:2054–2059CrossRefGoogle Scholar
  22. 22.
    Gebrehiwot T, San Sebastian M, Edin K et al (2014) Health workers’ perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia. BMC Pregnancy Childbirth 14:137CrossRefGoogle Scholar
  23. 23.
    Goodman DM, Srofenyoh EK, Olufolabi AJ et al (2017) The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana. BMC Pregnancy Childbirth 17:216CrossRefGoogle Scholar
  24. 24.
    Ndayizeye L, Ngarambe C, Smart B et al (2016) Peritonitis in Rwanda: epidemiology and risk factors for morbidity and mortality. Surgery 160:1645–1656CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Christophe Mpirimbanyi
    • 1
    Email author
  • Egide Abahuje
    • 2
  • Aime Dieudone Hirwa
    • 1
  • Miguel Gasakure
    • 1
  • Elisee Rwagahirima
    • 1
  • Christian Niyonzima
    • 1
  • Adolphe Niyoyita Hakizimana
    • 1
  • Epiphanie Ishimwe
    • 1
  • Faustin Ntirenganya
    • 1
    • 2
  • Jennifer Rickard
    • 2
    • 3
  1. 1.College of Medicine and Health SciencesUniversity of RwandaKigaliRwanda
  2. 2.University Teaching Hospital of KigaliKigaliRwanda
  3. 3.University of MinnesotaMinneapolisUSA

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