Title

Barriers to definitive hyper-acute management of stroke at a tertiary facility in Nairobi, Kenya

Date of Award

2019

Document Type

Dissertation

Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Dr. Dilraj Sokhi

Second Supervisor/Advisor

Dr. Jasmit Shah

Third Supervisor/Advisor

Dr. Peter Mativo

Department

Internal Medicine (East Africa)

Abstract

Background: Stroke is a sudden neurological deficit due to a vascular cause, which can be ischaemic, haemorrhagic stroke or another cause. It is a leading cause of disability and long term functional impairment in the world. The definitive management of an acute ischaemic stroke is thrombolysis and/or mechanical thrombectomy, both of which has been shown to improve functional outcome but the utilization remains quite low in most hospitals, especially in Africa. This is due to certain pre-hospital and in-hospital barriers, and these factors have been shown to differ from country to country.

Objective: To determine the pre-hospital barriers that prevent hyper-acute management of strokes at Aga Khan University Hospital Nairobi (AKUHN), categorized as patient/carer-specific factors including awareness of stroke, and system-related factors including transfer options to hospital. The secondary objectives were to determine: (i) stroke knowledge; (ii) in- hospital barriers that prevented hyper-acute management of strokes; and (iii) 30-day morbidity and mortality outcome measured using the modified Rankin Scale (mRS).

Methods: We conducted a descriptive cross-sectional study at AKUHN, where patients who presented to the hospital with a stroke were enrolled in the study. A standardized questionnaire was administered to the listed next of kin, or a relevant bystander at the time of the stroke, on behalf of the patient. The questionnaire captured demographic data, time and place of occurrence of stroke, mode of transport to the hospital, distance from place of stroke to hospital, amongst other factors, and also captured the understanding of stroke knowledge from the patient’s caregiver/bystander.

Results: The main pre-hospital barriers identified included delay in arrival (p <0.001) and this was due to far distance to the hospital (50.5%), traffic snarl ups (31.1%), visiting another hospital first (11.7%) and lack of availability of vehicle (6.8%). Factors associated with early hospital arrival (<3.5 hours of symptom onset), were older age (p = 0.021), non- African origin (p = 0.034), presence of a bystander (p = 0.006), residence in Nairobi (p = 0.035), and distance travelled (p < 0.001). There was no significance in the mRS between the early arrival (<3.5 hours) and the late arrival (>3.5 hours) group.

Conclusion: We identified significant pre-hospital barriers associated with delay of hospital arrival and subsequently delay of hyper-acute stroke management. These identified barriers require changes in pre-hospital emergency response services, improvement in stroke awareness including its treatment, and standardized in-hospital pathways to ensure improved quality of care to patients in Kenya.

This document is available in the relevant AKU library

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