Establishing the first stroke unit in Sierra Leone

Stroke is the second leading cause of adult death in Africa. Importantly, stroke is a preventable disease. Providing access to quality care and enabling healthier lifestyles can prevent strokes and reduce deaths from stroke. Due to this, in the last decades, rates of stroke have decreased in most European countries. However, stroke rates are increasing in most countries in Africa, and the policies and services to prevent and care for people with stroke are still in their infancy.

At Connaught Teaching Hospital in Sierra Leone, we see severe strokes occurring in young, previously fully able individuals. The stroke patients we see are on average, ten years younger than stroke patients in the UK. These patients of working age present with severe life changing stroke. Prior to their stroke, 93% of patients were completely independent; one year later less than 20% can function independently. Within one year, half of our stroke patients have died due to their stroke.

How can we improve the outcomes of people with stroke?

Research suggests that the most effective intervention for a population, is for patients to be cared for in a specialised stroke unit. This is the direction that Connaught Teaching Hospital, King’s and the Ministry of Health are taking with the development of a specialised stroke unit at Connaught.

Since the beginning of the year, a multidisciplinary team from Connaught Hospital has been trained at Korle Bu Teaching Hospital in Ghana.

The team of nurses, physiotherapists and doctors returned to Sierra Leone to implement a context appropriate, multidisciplinary stroke unit. The key elements of this stroke unit are its multidisciplinary staffing, acute management and monitoring of the patient, prevention and management of complications, positioning and mobilisation, combined with discharge planning and a longitudinal approach to care.

The eight-bed stroke unit admitted its first patient in July this year and since then has cared for over 50 patients.

The atmosphere on the stroke unit feels different to the other wards, a little calmer. The staff are on their feet more frequently, the relatives at the bedside less wary and more engaged with the care. Everyone writes in the same set of clinical notes. Ward rounds are becoming increasingly multi-disciplinary. The physios are on the ward daily, sitting up patients and helping them mobilise. Discharged patients come back to visit the clinical team on the ward. A culture and community is developing around those eight beds.

It is too early to know whether the stroke unit and its new culture will have a positive impact on patient outcomes, but the early signs look promising. In other countries, patients who receive this stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves.

Alongside evaluating the impact of stroke unit care on patient outcomes in Sierra Leone, the next step is to improve access to the service. In Sierra Leone,  the major barrier to accessing care is cost. Many stroke patients never make it to the hospital due to the prohibitive costs, and many, once there, cannot afford the 20 USD for a week of admission and care. Stroke units in the UK have been shown to be cost-effective; investing in them creates a healthier more productive population. There is an even greater argument to invest in stroke units in countries like Sierra Leone, where stroke rates are increasing and occur in younger working age adults. Investment should scale up coverage and access to these units, reducing admission fees and other barriers to access.

Beyond the impact on individual patients and families the stroke unit offers a vital opportunity for leveraging wider health system change. The stroke unit can demonstrate the value of multi-disciplinary team-based care; act as a model for continuity of care at the hospital, shifting systems of care to manage long-term conditions; and finally, demonstrate that partnership working can lead to sustained improvements in health outcomes.