Adaptation and validation of the Children’s Surgical Assessment Tool for Rwandan district hospitals

Figures & data

Table 1. Expert panellists.

		N = 18
Country
	Rwanda	14 (77.8%)
	USA*	4 (22.2%)
Role
	Pediatric Surgeon	6 (33.3%)
	Pediatric Anesthesiologist	5 (27.78%)
	General Surgeon	1 (5.56%)
	Surgical Sub-Specialty	2 (11.11%)
	Pediatrician	1 (5.56%)
	Health Systems Researcher	3 (16.67%)
Years Experience
	1–3	3 (16.67%)
	3–5	3 (16.67%)
	5–10	4 (22.22%)
	>10	8 (44.45%)
Institutions Represented**
	Centre Hospitalier Universitaire Kigali	8
	Rwanda Military Hospital	4
	King Faisal Hospital	1
	Butaro District Hospital	2
	Kirehe District Hospital	1
	University of Global Health Equity	3
	Partners in Health Rwanda	4
	Harvard Medical School	2
	Duke University Medical School	1
	University of Florida Medical School	1

*All panel members from the United States have at least 10 years of experience living and working in Rwanda.

**Several panelists represent and have worked for multiple institutions.

Table 2. (a-f) CSAT delphi method adaptation results.

Item	Round 1	Round 2 Score	Round 3 Score	Included in Final Tool?
a. FACILITY INFORMATION
Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children < 5 in a year	Introduced by Expert Panel	0.94	N/A	Yes
Total number of pediatric ED visits for children < 5 in a year	Introduced by Expert Panel	0.88	N/A	Yes
Total number of pediatric outpatient visits for children < 5 in a year	Introduced by Expert Panel	0.88	N/A	Yes
Total number of children’s surgical admissions for children < 5 in a year	Introduced by Expert Panel	0.94	N/A	Yes
Total number of children’s surgical outpatients (visits) for children < 5 seen in a year	Introduced by Expert Panel	0.88	N/A	Yes
Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children 5–15 years-old in a year	Retained from CSAT	0.88	N/A	Yes
Total number of pediatric ED visits for children 5–15 years-old in a year	Introduced by Expert Panel	0.71	0.94	Yes
Total number of pediatric outpatient visits for children 5–15 years-old in a year	Introduced by Expert Panel	0.71	0.76	Yes
Total number of children’s surgical admissions for children 5–15 years-old in a year	Retained from CSAT	0.76	N/A	Yes
Total number of children’s surgical outpatients (visits) for children 5–15 years-old seen in a year	Retained from CSAT	0.82	N/A	Yes
Total number of inpatient hospital beds dedicated to children’s surgery	Retained from CSAT	0.82	N/A	Yes
Does your hospital have a pediatric recovery room?	Introduced by Expert Panel	0.76	N/A	Yes
Total number of recovery room hospital beds dedicated to children’s surgery	Introduced by Expert Panel	0.82	N/A	Yes
Is oxygen available in the recovery room?	Introduced by Expert Panel	1.00	N/A	Yes
Total number of operating rooms in the hospital	Introduced by Expert Panel	0.88	N/A	Yes
Total number children’s operating rooms	Retained from CSAT	0.82	N/A	Yes
Total number of neonatal unit/special baby care unit beds	Retained from CSAT	1.00	N/A	Yes
Does your hospital have a post-operative ICU?	Introduced by Expert Panel	0.88	N/A	Yes
Total number of pediatric ICU/advanced care beds	Retained from CSAT	0.88	N/A	Yes
Total number of neonatal ICU beds	Retained from CSAT	0.82	N/A	Yes
Total number of functional pediatric ventilators in the ICU	Retained from CSAT	0.82	N/A	Yes
Total number of functional neonatal ventilators in ICU	Retained from CSAT	0.76	N/A	Yes
Total number of functional incubators or pediatric warmers	Modified	0.94	N/A	Yes
Total number of patient monitors in pediatric and neonatal ICU	Retained from CSAT	0.88	N/A	Yes
How many of these monitors include all of the following: EKG, blood pressure, pulse oximetry, temperature and capnography?	Introduced by Expert Panel	0.88	N/A	Yes
How many patients <5 years old per year do you refer to higher-level facilities for surgical interventions?	Introduced by Expert Panel	0.88	N/A	Yes
How many patients 5–15 years old per year do you refer to higher-level facilities for surgical interventions?	Retained from CSAT	0.88	N/A	Yes
What is the most common reason for referral of pediatric surgical patients <5 years old to higher levels of care?	Introduced by Expert Panel	0.94	N/A	Yes
What is the most common reason for referral of pediatric surgical patients 5–15 years old to higher levels of care?	Retained from CSAT	0.94	N/A	Yes
How far away is the nearest referral hospital (hours, by car)	Introduced by Expert Panel	0.94	N/A	Yes
b. INFRASTRUCTURE
24-hour Emergency Unit able to receive pediatric patients	Retained from CSAT	1.00	N/A	Yes
Pediatric malnutrition feeding program	Introduced by Expert Panel	0.71	0.71	Yes
Pediatric dosing cognitive aid or guide	Introduced by Expert Panel	0.76	N/A	Yes
Does your hospital have a radiologist?	Retained from CSAT	0.82	N/A	Yes
Does your hospital have an anesthesiologist who can perform sedation?	Modified	0.94	N/A	Yes
Enteral contrast material for bowel evaluation (barium or gastrografin)	Retained from CSAT	0.69	0.50	Yes
Intravenous contrast material	Retained from CSAT	0.63	0.31	No
Echocardiogram	Retained from CSAT	0.80	N/A	Yes
Ultrasound	Introduced by Expert Panel	1.00	N/A	Yes
X-ray	Introduced by Expert Panel	1.00	N/A	Yes
Anatomic Pathology services	Retained from CSAT	0.63	0.56	Yes
Blood component transfusion	Retained from CSAT	0.94	N/A	Yes
c. SERVICE DELIVERY
Suturing laceration	Retained from CSAT	0.94	N/A	Yes
Drainage of superficial abscess	Retained from CSAT	1.00	N/A	Yes
Wound debridement	Retained from CSAT	1.00	N/A	Yes
Biopsy (tumour)	Retained from CSAT	0.88	N/A	Yes
Male circumcision	Retained from CSAT	1.00	N/A	Yes
Management of non-displaced fractures	Retained from CSAT	1.00	N/A	Yes
Removal of foreign body from ear/nose	Retained from CSAT	1.00	N/A	Yes
Support for emergency airway obstruction	Modified	0.94	N/A	Yes
Eyelid surgery for trachoma	Retained from CSAT	0.73	0.47	No
Reduction of dislocation	Introduced by Expert Panel	0.94	N/A	Yes
Reduction and application of splint for non-displaced fractures	Introduced by Expert Panel	1.00	N/A	Yes
IV placement for neonates	Introduced by Expert Panel	0.94	N/A	Yes
Appendectomy	Retained from CSAT	0.88	N/A	Yes
Laparoscopy for typhoid peritonitis	Introduced by Expert Panel	0.56	0.38	No
Hernia/hydrocele repair	Introduced by Expert Panel	0.93	N/A	Yes
Non-operative reduction of intussusception	Introduced by Expert Panel	0.88	N/A	Yes
Operative reduction of intussusception	Modified	0.88	N/A	Yes
Bowel resection	Retained from CSAT	0.87	N/A	Yes
Temporizing measures for gastroschisis and omphalocele (cover and rehydration) prior to referral	Modified	0.94	N/A	Yes
Rectal biopsy	Retained from CSAT	0.56	0.69	Yes
Resection of solid abdominal masses	Retained from CSAT	0.63	0.73	Yes
Creation of intestinal stomas	Retained from CSAT	0.94	N/A	Yes
Closures of intestinal stomas	Retained from CSAT	0.81	N/A	Yes
Emergency ostomies for imperforate anus	Introduced by Expert Panel	0.81	N/A	Yes
Resuscitation for pyloric stenosis	Modified	0.94	N/A	Yes
Catheterization/suprapubic cystostomy	Retained from CSAT	1.00	N/A	Yes
Orchiopexy	Retained from CSAT	0.88	N/A	Yes
Repair of testicular or ovarian torsion	Retained from CSAT	0.88	N/A	Yes
Thyroidectomy (total or partial)	Retained from CSAT	0.38	0.44	No
Drainage of septic arthritis/osteomyelitis	Retained from CSAT	0.93	N/A	Yes
Repair of cleft lip and/or palate	Retained from CSAT	0.53	0.59	Yes
Central Lines	Removed	N/A	N/A	No
Emergency Surgical airway (cricothyroidotomy)	Modified	0.94	N/A	Yes
Emergency Tube thoracostomy	Modified	0.94	N/A	Yes
Trauma Laparotomy	Retained from CSAT	0.88	N/A	Yes
Conservative (non-operative) management for simple humeral fracture	Introduced by Expert Panel	0.88	N/A	Yes
Open reduction and internal fixation	Retained from CSAT	0.73	0.88	Yes
Placement of pediatric external fixator	Retained from CSAT	0.75	N/A	Yes
Emergency Escharotomy/fasciotomy	Modified	0.75	N/A	Yes
Contracture release	Modified	0.56	0.63	Yes
Amputations	Retained from CSAT	0.94	N/A	Yes
Skin grafting	Retained from CSAT	0.67	N/A	Yes
Emergency Burr hole	Modified	0.80	N/A	Yes
Emergency Craniotomy	Modified	0.80	N/A	Yes
Surgery for neonatal acute abdomen	Introduced by Expert Panel	0.81	N/A	Yes
Repair of club foot	Retained from CSAT	0.57	0.65	Yes
Placement and management of external ventricular drain	Modified	0.73	0.50	No
Definitive repair of non-complicated anorectal malformation or Hirschsprung’s Disease	Modified	0.63	0.50	No
Repair of esophageal atresia	Removed	N/A	N/A	No
Repair of intestinal atresia	Removed	N/A	N/A	No
Myelomeningocele reapir	Removed	N/A	N/A	No
Atrial/Ventricular Septal Defect Repair	Removed	N/A	N/A	No
Number of pediatric laparotomies (<5 y/o) performed last year	Introduced by Expert Panel	0.88	N/A	Yes
Number of pediatric laparotomies (5–15 y/o) performed last year	Retained from CSAT	0.88	N/A	Yes
Number of elective hernia repairs (<5 y/o) last year	Introduced by Expert Panel	0.88	N/A	Yes
Number of elective hernia repairs (5–15 y/o) last year	Introduced by Expert Panel	0.88	N/A	Yes
Number of neonatal (<1 month age) stomas performed last year	Retained from CSAT	0.82	N/A	Yes
Number of surgical repairs of pediatric (<5 y/o) open fractures performed last year	Introduced by Expert Panel	0.82	N/A	Yes
Number of surgical repairs of pediatric (5–15 y/o) open fractures performed last year	Modified	0.82	N/A	Yes
Total number of procedures performed in pediatric patients (<5 years) last year	Introduced by Expert Panel	0.88	N/A	Yes
Total number of procedures performed in pediatric patients (5–15 years) last year	Retained from CSAT	0.88	N/A	Yes
Percent of < 5 surgery cases that were emergent or urgent (non-elective) cases	Introduced by Expert Panel	0.94	N/A	Yes
Percent of 5–15 surgery cases that were emergent or urgent (non-elective) cases	Retained from CSAT	0.82	N/A	Yes
At what age do you start performing elective hydrocele/hernia repair?	Introduced by Expert Panel	0.76	N/A	Yes
Is your institution involved in a formal training program for surgical trainees?	Retained from CSAT	0.65	0.76	Yes
Does your institution have a method of monitoring surgical outcomes over time?	Retained from CSAT	0.82	N/A	Yes
Does your institution use electronic medical records?	Retained from CSAT	0.69	0.76	Yes
Does your institution have a trauma registry that includes pediatric trauma?	Retained from CSAT	0.76	N/A	Yes
Number of post-operative pediatric (<5 y/o) in-hospital deaths last year	Introduced by Expert Panel	0.88	N/A	Yes
Number of post-operative pediatric (5–15 y/o) in-hospital deaths last year	Retained from CSAT	0.82	N/A	Yes
Number of surgical site infections(SSIs) in pediatric patients (<15 y/o) in the last year ssi_all	Retained from CSAT	0.82	N/A	Yes
What is the highest ASA class of children operated at your institution? (ASA I = healthy patient, ASA II = patient with mild systemic disease, ASA III = patient with severe systemic disease, ASA IV = patient with severe systemic disease that is a constant threat to life)	Modified	0.82	N/A	Yes
Is the WHO Surgical Safety Checklist used in the operating rooms for pediatric patients?	Retained from CSAT	0.94	N/A	Yes
Is pulse oximetry used in the operating rooms for pediatric patients?	Retained from CSAT	1.00	N/A	Yes
How often does the hospital hold a surgical audit (Mortality and Morbidity conference) related to children’s surgical patients?	Retained from CSAT	0.82	N/A	Yes
Functional anesthesia machines with pediatric breathing system	Modified	0.82	N/A	Yes
Pediatric oropharyngeal airway (000–4)	Retained from CSAT	0.88	N/A	Yes
Pediatric endotracheal tubes (2.5–6 mm)	Retained from CSAT	0.93	N/A	Yes
Pediatric laryngoscope(Miller ≤2 or Macintosh ≤ 3)	Retained from CSAT	0.87	N/A	Yes
Pediatric facemask bag valve or Ambu bag (<550 ml bag with < size 3 mask)	Modified	0.94	N/A	Yes
Pediatric difficult airway kit (LMA)	Retained from CSAT	0.94	N/A	Yes
Pediatric Magill forcep	Retained from CSAT	0.88	N/A	Yes
Pediatric blood pressure monitor or cuff	Retained from CSAT	0.94	N/A	Yes
Pediatric pulse oximetry	Retained from CSAT	1.00	N/A	Yes
Pediatric nasogastric Tube (<12 Fr)	Retained from CSAT	0.94	N/A	Yes
Pediatric chest tubes (<20 Fr)	Retained from CSAT	0.94	N/A	Yes
Pediatric surgical instruments	Retained from CSAT	0.81	N/A	Yes
Pediatric urinary catheters (<12 Fr)	Retained from CSAT	1.00	N/A	Yes
Pediatric central lines (<7 Fr or 12 cm)	Retained from CSAT	0.81	N/A	Yes
Sutures (3.0, 4.0, 5.0, 6.0)	Modified	0.88	N/A	Yes
Minimally invasive equipment (laparoscopy, arthroscopy, and thoracoscopy)	Retained from CSAT	0.69	0.47	No
Capnography (exp. CO2 measurement)	Retained from CSAT	0.75	N/A	Yes
Pre-formed intestinal silos or pre-formed/readily available silos created from plastic bags	Modified	0.67	0.69	Yes
d. WORKFORCE
Number of qualified general surgeons with pediatric exposure (trained surgeons with expertise in pediatric or neonatal surgery, but without formal subspecialty pediatric surgical training)	Retained from CSAT	0.88	N/A	Yes
Number of qualified general pediatric surgeons (trained surgeons with formal specialized training in children’s surgery of ≥1 year)	Retained from CSAT	0.82	N/A	Yes
Number of general doctors providing pediatric surgery (general practitioners without formal surgical training)	Retained from CSAT	0.82	N/A	Yes
Number of non-physicians providing pediatric procedure (non-physicians health care professional who performs procedures independently without formal training in surgery). These procedures include: circumcision, reduction of closed fractures, small wound repair, debridement, minor skin grafts.	Retained from CSAT	0.76	N/A	Yes
Number of qualified pediatric anesthesiologists (trained anesthesiologists with formal specialization in pediatric anesthesia of ≥1 year)	Retained from CSAT	0.88	N/A	Yes
Number of general doctors providing pediatric anesthesia (general practitioners without formal anesthesiology training)	Retained from CSAT	0.65	0.80	Yes
Number of non-physicians providing pediatric anesthesia (non-physicians health care professionals who perform pediatric anesthesia independently without formal training in anesthesia)	Retained from CSAT	0.88	N/A	Yes
Number of nurses with training or exposure in pediatric surgery, who treat only children	Retained from CSAT	0.82	N/A	Yes
Number of visiting or consultant physicians who are involved in pediatric surgical care (visiting at least 1×/week for at least 1 year).	Introduced by Expert Panel	0.71	0.88	Yes
Please identify pediatric specialists that are available at your hospital: General Pediatrician	Retained from CSAT	1.00	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Cardiac surgeon	Retained from CSAT	0.53	0.59	Yes
Please identify pediatric specialists that are available at your hospital: Dental surgeon	Retained from CSAT	0.76	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Neurosurgeon	Retained from CSAT	0.63	0.65	Yes
Please identify pediatric specialists that are available at your hospital: Ophthamologist	Retained from CSAT	0.71	0.65	Yes
Please identify pediatric specialists that are available at your hospital: Orthopedic surgeon	Retained from CSAT	0.82	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Otorhinolaryngologist (ENT)	Retained from CSAT	0.76	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Plastic surgeon	Retained from CSAT	0.76	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Urologist	Retained from CSAT	0.71	0.65	Yes
Please identify pediatric specialists that are available at your hospital: Hematologist	Retained from CSAT	0.69	0.47	No
Please identify pediatric specialists that are available at your hospital: Nephrologist	Retained from CSAT	0.65	0.47	No
Please identify pediatric specialists that are available at your hospital: Neurologist	Retained from CSAT	0.63	0.53	Yes
Please identify pediatric specialists that are available at your hospital: Respiratory Physician	Retained from CSAT	0.71	0.65	Yes
Please identify pediatric specialists that are available at your hospital: Neonatologist	Retained from CSAT	0.82	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Cardiologist	Retained from CSAT	0.71	0.71	Yes
Please identify pediatric specialists that are available at your hospital: Endocrinologist	Retained from CSAT	0.65	0.65	Yes
Please identify staff members that are available at your hospital: Oncologist treating children	Retained from CSAT	0.76	N/A	Yes
Please identify pediatric specialists that are available at your hospital: Physiotherapist	Introduced by Expert Panel	0.65	0.76	Yes
Please identify staff members that are available at your hospital: Pediatric intensive care nurse	Retained from CSAT	0.88	N/A	Yes
Please identify staff members that are available at your hospital: Neonatal nurse	Retained from CSAT	0.81	N/A	Yes
Please identify staff members that are available at your hospital: Qualified nutritionist	Retained from CSAT	0.76	N/A	Yes
Please identify staff members that are available at your hospital: Radiographer	Retained from CSAT	0.82	N/A	Yes
Please identify staff members that are available at your hospital: Radiologist	Retained from CSAT	0.82	N/A	Yes
Please identify staff members that are available at your hospital: Speech therapist	Introduced by Expert Panel	0.65	0.65	Yes
Please identify staff members that are available at your hospital: Audiometrist	Retained from CSAT	0.53	0.65	Yes
Please identify staff members that are available at your hospital: Pathologist	Retained from CSAT	0.71	0.71	Yes
Please identify staff members that are available at your hospital: Ophthalmology technician	Introduced by Expert Panel	0.71	0.75	Yes
How often are these available 24 hours a day?: General surgeon or pediatric surgeon	Retained from CSAT	0.82	N/A	Yes
How often are these available 24 hours a day?: Pediatric anesthesia provider availability (with >6 months of training or exposure in pediatrics)	Retained from CSAT	0.88	N/A	Yes
e. FINANCING
What percentage of children coming to this hospital have health insurance	Retained from CSAT	0.88	N/A	Yes
Nationally, is there government-sponsored health insurance/financing for children?	Retained from CSAT	0.82	N/A	Yes
On average, what percentage pediatric surgical costs for patients are covered by insurance?	Retained from CSAT	0.88	N/A	Yes
Annual hospital budget allotted to children’s surgery and anesthesia	Retained from CSAT	0.88	N/A	Yes
Average total inpatient cost for a patient for: pediatric hernia repair	Retained from CSAT	0.71	0.82	Yes
Average total inpatient cost for a patient for: pediatric open fracture repair	Retained from CSAT	0.71	0.82	Yes
Average total inpatient cost for a patient for: pediatric laparotomy	Retained from CSAT	0.76	N/A	Yes
Average total inpatient cost for a patient for: Pediatric appendectomy	Introduced by Expert Panel	0.76	N/A	Yes
Average total inpatient cost for a patient for: repair of Hirschprung’s disease/anorectal malformation	Removed	N/A	N/A	No
Average non-medical/additional cost to a patient for a pediatric appendectomy (transport, food/lodging, missed work for family members)	Introduced by Expert Panel	0.76	N/A	Yes
f. TRAINING AND RESEARCH
How many ongoing research projects involve children’s surgery (this may include quality improvement projects)?	Modified	0.71	0.88	Yes
How many ongoing research projects involve pediatric anesthesia?	Retained from CSAT	0.71	0.82	Yes
How many ongoing research projects involve pediatric nursing?	Retained from CSAT	0.71	0.88	Yes
How many workshops, trainings, and lectures related to pediatric surgery or perioperative care are in an average month?	Retained from CSAT	0.88	N/A	Yes

*Items that scored 0.75 or above in Round 2 were retained and not further discussed in Round 3. These are listed as N/A below.