A Quality Audit on the management of acute ischaemic stroke at Kenyatta National Hospital

Abstract

Background Stroke mortality is high and rising in developing countries including Kenya. Eighty four percent of stroke victims in these countries die within 3 years of diagnosis compared to16% of those living in high income countries. This disparity is largely attributable to the care given in the acute setting after onset of stroke. Though stroke is now considered a treatable medical emergency, the care of stroke patients is still suboptimal in much of SSA. This is due to wide gaps between evidence based guideline recommendations and actual clinical practice as affected not only by availability of resources but also inertia and inefficiency in health service provision. In view of this, professional neurological societies developed quality assessment tools that can be used to monitor and improve the care given to stroke patients. Institutions that carry out regular audits have been shown to have consistent improvements in the outcome of their stroke patients. Objectives Primary objective 1. To assess the management of acute ischaemic stroke and determine the proportion of stroke patients receiving the recommended stroke care according to the American Stroke Association quality indicators. Secondary objectives 1. To evaluate knowledge on standard stroke care among health care providers in KNH. Active Form Group: Stroke 2. To assess the main barriers to providing recommended stroke care interventions. Methods The study design was mixed. First, there was a retrospective file audit of patients admitted with acute ischaemic stroke over a period of one year (2018). Secondly, we employed a quantitative cross sectional design to assess health care provider‟s knowledge on stroke care. Lastly, we carried out a qualitative cross sectional assessment of the main barriers to quality stroke care. The ASA-GWTG audit tool was used to document the extent to which stroke care processes approximated recommended guidelines. The score for each process was calculated as a percentage of patients documented to have received the care process (quality indicator) versus the total number eligible. Knowledge on stroke among health care providers was assessed quantitatively using questionnaires and the scores expressed as a percentage of correct answers by the respondents. Barriers to stroke care were assessed using semi structured voice recorded interviews of key informants and thematic analysis was done for the data obtained. Results A total of 160 files records were reviewed. We found low and variable adherence to stroke quality indicators. Eighty three percent of the patients had brain imaging done by day one but none of them had thrombolysis. Dysphagia screening was considered done in 7%. Antiplatelets administration by day 2 was met in 48% of the patients. Venous thromboembolism prophylaxis was documented in 65% while 78% of the patients in atrial fibrillation had anticoagulation therapy. Fifty eight percent of the patients had physiotherapy done. Less than 1% of the patients were documented to have been educated stroke. There was no documentation of advice against Active Form Group: Stroke smoking to any of the active smokers. Seventy five percent of the patients were discharged on an antiplatelet and 59% went home on a cholesterol lowering agent. On assessment of knowledge of health care workers on stroke, most internal medicine residents had sufficient knowledge on acute stroke care. Their mean score 73%, but the mean score for the medical officers was 55%. The nurses had a low mean score at 39%. We found eight key barriers to standard stroke care. At the patient level, there were delays in presentation, financial constraints and low level of awareness on stroke. At the hospital level, there was lack of stroke care protocols, low awareness among lower cadre providers, inadequate staff, insufficient equipment and limited funding from the national government. Conclusion KNH had overall low and variable scores across the stroke performance measures. Health care workers demonstrated a wide variability in their stroke knowledge on stroke. There were multiple barriers to optimal stroke care at the patient level, hospital level and national level.