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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018
178
AFRICA
of care. To complement our quantitative evaluation of current
ACS care at Kenyatta National Hospital, we also conducted
a prospective qualitative analysis to understand facilitators of,
barriers to and the context of in-hospital ACS care. We sought to
identify knowledge, attitude and behaviour about interventions
for improvement of quality of healthcare through in-depth
interviews with healthcare providers involved in the management
of ACS patients at Kenyatta National Hospital. This qualitative
evaluation will provide informative data for future activities to
improve quality of care in the hospital and region.
Methods
This qualitative study included in-depth interviews of key
participants who were healthcare providers involved in the
management of ACS patients at Kenyatta National Hospital,
which is one of the two main public referral centres in Kenya. The
hospital has Kenya’s most advanced diagnostic and management
capabilities for ACS care, including having the only public
cardiac catheterisation laboratory in the country.
We developed interview guides to explore facilitators of,
barriers to and context of in-hospital ACS care at Kenyatta
National Hospital. We modelled this qualitative study based
on our team’s prior research in India, which has led to the
development of a theoretical model that viewed ACS care
through a patient-orientated process map including five stages:
(1) prior to first medical contact, (2) at the point of first medical
contact, (3) early hospitalisation, (4) mid-to-late hospitalisation,
and (5) at the point of discharge.
4
Starting in January 2017, we selected an initial sample
of hospital leaders for interviewing and used a snowballing
technique to identify additional participants during February
2017. We used the principle of maximal variability sampling to
seek new participants to achieve a diverse sample. We continued
our recruitment until we achieved saturation of major themes
identified during our analysis.
All interviews with audio recordings were conducted by one
interviewer (EB) in English and lasted between 36 and 65 minutes.
Audio transcripts and interview field notes of the first three
transcripts were independently coded by two individuals (EB,
SV) to develop a comprehensive codebook. The same coders used
Dedoose version 7.5.27
5
to code the remaining transcripts and field
notes using the codebook. We also developed and implemented
a brief survey to capture demographic data and open-ended
responses regarding facilitators of, barriers to and context of ACS
care, which were further explored in the in-depth interviews.
The study was approved by the University of Washington
institutional review board, the Kenyatta National Hospital/
University of Nairobi ethics and research committee and
Northwestern University institutional review board. Written
informed consent was obtained from all participants.
Results
We conducted 16 interviews during the study period, including
with one cardiologist, two accident and emergency (A&E)
attending physicians, two medical officers in the casualty
department, three A&E nurses, and eight medical registrars
(Table 1). More than half (56%) of the interviewees were women.
We also provide a summary of the major facilitators of and
barriers to ACS care at Kenyatta National Hospital that were
highlighted by most participants in Tables 2 and 3, respectively.
Theme 1: There is a significant delay from onset
of patient symptoms to presentation at Kenyatta
National Hospital
All participants explained that there is a significant delay from
symptom onset to presentation at Kenyatta National Hospital,
which seems largely driven by a lack of patient understanding of
ACS symptoms that warrant emergent medical attention. This
delay is further exacerbated by the inter-hospital transfer system
from district hospitals to Kenyatta National Hospital.
‘Of course, from the patient side, delay is a big problem and
therefore once they come late we end up doing heart-failure
management post MI, many of our people do not have the
knowledge that if I have a chest pain, I need to rush to
hospital…So, knowledge in our community is an area that
we need to educate the community about chest pain’
Other respondents described patients seeking care at pharmacies
rather than hospitals, for initial management.
‘Significant delay in presentation from symptom onset
because most of the time most Kenyans usually try and
buy over-the-counter medications and don’t present unless
the pain is severe.’
Table 1. Participants’ characteristics
Participants
Number = 16 (%)
Type of ACS provider
Cardiologist
1 (6)
A&E room attendants
2 (13)
A&E room medical officers
2 (13)
Nurses
3 (19)
Medical residents
8 (50)
Female
9 (56)
Table 2. Facilitators of in-hospital ACS management at Kenyatta National Hospital
Hospital level
Provider level
• The hospital is one of a few institutions that has diagnostics including ECG and echocardiography, and is the only
public hospital with a cardiac catheterisation laboratory, although availability of some of these diagnostic services
are limited and could be improved
• Guideline-directed in-patient and discharge. Medical therapy, specifically antiplatelet agents, beta-blockers, statins,
anticoagulants and ACE inhibitors are largely available
• Hospital-fee waiver for certain services is available for patients who are unable to afford emergency medical treatment
• The hospital has critical care units, both in the casualty department and medical wards, to take care of critically ill
patients, including ACS patients
• Structured follow-up mechanism post discharge through the cardiology clinic
• Continuing medical education programmes that cover current ACS treatment guidelines
• Availability of expert staff including cardi-
ologists, well-trained critical-care nursing
staff and medical registrars
• Well-trained echocardiography technicians
• Providers that participated in this qualita-
tive research displayed great interest in
improving existing ACS care, including
potential quality improvement