Shortfall in stroke care: A study of ischaemic stroke care practices in a South African metropole

In recent years there have been significant advances in the management of stroke. In particular, reperfusion therapies have been shown to confer significant benefit, with the possibility of reversing ischaemic stroke or reducing disability when administered to suitable patients. However, these therapies also carry significant risk, including death. The South African (SA) and other international guidelines for stroke care provide recommendations to optimise benefit and reduce risk of these novel treatments. Failure to adhere to recommended guidelines can lead to increased preventable morbidity and mortality in such patients.

To describe the acute and post-acute ischaemic stroke services offered to patients in level 1, 2 and 3 hospitals in the Cape Metro Health District, determine levels of adherence to the SA stroke guideline, and identify barriers to optimal stroke patient care.

This study in five level 1, one level 2 and two level 3 public hospitals involved semi-structured interviewer-administered questionnaires and reviews of ischaemic stroke patient discharge summaries, hospital staffing, stroke protocols, diagnostic investigations available and stroke education for patients and their caregivers. The findings were then compared with recommendations in the national guideline.

Twenty-eight participants (18 doctors, 10 nurses) from the general medical wards, stroke units and emergency units of eight hospitals were invited to participate in interviews. Most level 1 and 2 hospitals experienced difficulties transferring patients to higher levels of care. There was also limited access to stroke management protocols, inadequate stroke education among health professionals, pre- and in-hospital delays in patients receiving medical attention, and limited access to diagnostic investigations. As only a total of 12 stroke unit beds were available at the two level 3 hospitals, the majority of ischaemic stroke patients were admitted to the general medical wards of level 1, 2 and 3 hospitals. The level of care at all these facilities was not homogeneous.

The two stroke units at the level 3 hospitals adhered most closely to the recommended SA stroke guideline. Elsewhere, ischaemic stroke care varied widely across general medical wards at all hospital levels. Adherence to the guideline was influenced by factors such as limited access to diagnostic investigations, patient delays in receiving medical attention, and shortages of staff. Monitoring systems for continuous evaluation of the quality of acute and post-acute stroke services are needed. The shortfall in compliance with recommended stroke treatment guidelines could lead to worse outcomes and exposure to litigation.