Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

Abstract

Introduction In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. Methods We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. Results Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). Conclusion Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

Clinical Characteristic of a Haitian Stroke Cohort and a scoping review of the literature of stroke among the Haitian population

“…Like our study, the mean age of stroke among these Haitian populations is 10 years younger than for developed countries highlight that stroke affects Haitians at their economic prime. 30,31 Rouhani also document delays in care including delays to arrival time and CT imaging confirming a prolonged time to treatment. 31 Together with our current study, these papers demonstrate the need for ongoing research and stroke interventions to save lives and prevent stroke related disability among the Haitian population.…”

“…30,31 Rouhani also document delays in care including delays to arrival time and CT imaging confirming a prolonged time to treatment. 31 Together with our current study, these papers demonstrate the need for ongoing research and stroke interventions to save lives and prevent stroke related disability among the Haitian population.…”