New stroke unit sees reduction in stroke mortality at Connaught Hospital, Sierra Leone

The eight-bed stroke unit was opened in July 2022, following the recommendations of the Stroke in Sierra Leone research study,¹ which found that stroke in Sierra Leone occurs at an average age of 59 years, 10-15 years younger than in Western Europe.² The majority of stroke patients are therefore of working age and 43% are the main breadwinner for their family. Quality of care in the hospital was previously poor³ and patient outcomes were correspondingly poor, with half of all stroke patients dying within one year of their stroke.²

After an inspirational visit to Korle Bu Hospital Stroke Unit in Ghana, a multidisciplinary team from Connaught Hospital implemented stroke unit-based care for the first time in Sierra Leone. 

To mark this one-year anniversary, the stroke unit team invited the Stroke Association Sierra Leone, the hospital management and the Ministry of Health (MoH) to visit the unit and review progress.

A simple, before-after analysis of audit data was undertaken to assess the impact of the new stroke unit. Twelve months of data from July 2022 until July 2023 (intervention period) was compared to 12 months of data collected between May 2019 until April 2020 (comparison period).* 

Since the stroke unit opened:

• The quality of care; swallow assessments; aspirin for ischaemic stroke; statin prescription and physiotherapy have all improved significantly for patients admitted to the stroke unit.

   

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  Stroke mortality at Connaught Teaching Hospital has reduced, from 39.2% to 26.6% of patients admitted in the stroke unit. Stroke mortality for patients not admitted to the stroke unit has also reduced but remains higher than the stroke unit at 32.1%.

In the comparison period, 385 patients were admitted to the hospital. In the intervention period, 302 stroke patients were admitted to the hospital, of whom 109 were admitted to the stroke unit and 193 were admitted to the normal wards. The patient socio-demographics and the severity of their stroke were roughly the same in the two periods. The four indicators of quality of care measured during audit all significantly improved with introduction of the stroke unit (Table one).

Table one: Quality of care indicators in the comparison period, pre-stroke unit and for patients admitted to the stroke unit

The proportion of patients who suffered a complication related to their stroke was 191/385 (49.6%) in the comparison period and 31/109 (28.4%) for patients admitted to the stroke unit. In hospital mortality in the comparison period was 39.2% (151/385), compared to 26.6% (29/109) for patients admitted to the stroke unit. Stroke mortality for patients not admitted to the stroke unit has also reduced compared to the comparison period but remains higher than for patients admitted to the stroke unit at 32.1% (62/193).

Whilst care and survival are improved inside the stroke unit, only 36% (109/302) of stroke patients at Connaught receive stroke unit care. The principal barrier to stroke unit care at Connaught is the cost of the CT Brain scan, which the majority of patients cannot afford. Connaught is the only stroke unit in the country and the rest of the country is underserved. The MoH plans to develop stroke units at regional hospitals, in an effort to address the geographical barriers to access.

At a recent meeting focusing on stroke care, the Deputy Chief Medical Officer, Dr Mustapha Kabba, from the MoH praised the stroke unit team for their strives in improving quality of care. Reflecting on the issues of access to care he remarked, 

In line with increasing access to improved stroke care, the MoH has invited the Connaught stroke unit team to visit Kenema Government Hospital, to evaluate how care for people with stroke can be improved outside of the capital Freetown.

Beyond the impact on individual patients and families, the stroke unit is also an example which can inform wider hospital and health system practice.  The stroke unit acts as a model of multi-disciplinary, team-based working and demonstrates the value of simple, quality improvement methods in improving patient outcomes.

References

^1. Youkee D, Marshall IJ, Fox-Rushby J, Lisk DR, O’Hara J, Wang Y, et al. Cohort Profile: The Stroke in Sierra Leone (SISLE) Register. International Journal of Epidemiology. 2023.

^2. Youkee D, Deen G, Baldeh M, Conteh ZF, Fox-Rushby J, Gbessay M, et al. Stroke in Sierra Leone: Case fatality rate and functional outcome after stroke in Freetown. Int J Stroke. 2023:17474930231164892

^3. Youkee D, Deen G, Barrett E, Fox-Rushby J, Johnson I, Langhorne P, et al. A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes. Frontiers in Neurology. 2021;12.

^*Caution should be taken in the interpretation of this data, as it is audit data, and likely includes bias.