School of Public Health and Family Medicine, University of Cape Town, South Africa.
S Afr Med J. 2021 Mar 2;111(3):215-219. doi: 10.7196/SAMJ.2021.v111i3.15104.
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.
近年来，中风的治疗取得了重大进展。特别是，再灌注疗法已被证明能带来显著的益处，为合适的患者进行治疗可能逆转缺血性中风或降低残疾程度。然而，这些疗法也存在很大的风险，包括死亡。南非（SA）和其他国际中风护理指南提供了优化这些新疗法的益处和降低风险的建议。不遵守推荐的指南可能导致此类患者的可预防发病率和死亡率增加。
描述开普敦大都市区一级、二级和三级医院为缺血性中风患者提供的急性和后期中风服务，确定对南非中风指南的遵循程度，并确定最佳中风患者护理的障碍。
这项在五所一级、一所二级和两所三级公立医院进行的研究包括对 8 家医院的普通病房、中风病房和急诊室的中风患者出院记录、医院工作人员、中风方案、可用的诊断性检查以及中风患者及其护理人员的教育进行半结构式访谈。然后将这些发现与国家指南中的建议进行比较。
来自 8 家医院的普通病房、中风病房和急诊室的 28 名参与者（18 名医生，10 名护士）被邀请参加访谈。大多数一级和二级医院在将患者转移到更高水平的治疗方面都存在困难。也存在获取中风管理方案的限制，卫生专业人员中风教育不足，患者在接受医疗关注时的预住院和院内延误，以及诊断性检查的限制。由于两所三级医院总共只有 12 张中风病房床位，因此大多数缺血性中风患者被收治在一级、二级和三级医院的普通病房。所有这些设施的护理水平都不一致。
两所三级医院的中风病房最严格地遵循了推荐的南非中风指南。在其他地方，普通病房的中风护理在所有医院级别都存在很大差异。对指南的遵循受到一些因素的影响，如诊断性检查的获取受限、患者接受医疗关注的延迟，以及工作人员的短缺。需要监测系统来持续评估急性和后期中风服务的质量。不遵守推荐的中风治疗指南可能导致更糟糕的结果和暴露于诉讼之中。
