49 / 76
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018
AFRICA
179
Inter-hospital transfer delays are also driven by delays in
diagnosis at district-level hospitals as well as limited access to
ambulances for rapid transport.
‘Our hospital, of course, is a national hospital, so many
times we get patients who have been referred and therefore
they would have passed one or two other hospitals, being
managed for either pneumonia or for an abdominal
problem, so they tend to come late.’
Theme 2: Diagnostic, management and treatment
capabilities of the hospital are sub-optimal
Theme 2.1: Availability of electrocardiogram (ECG)
and cardiac biomarkers
Respondents all agreed that the limited availability of functioning
ECG machines in the hospital creates a significant barrier
to rapid ACS diagnosis. Some patients are referred from the
A&E department to the out-patient cardiology department
for acute ECG monitoring, whereas other patients do not
receive an ECG during their hospitalisation. This assessment
parallels findings from our study that retrospectively evaluated
current ACS management trends at Kenyatta National Hospital,
which showed the rate of ECG acquisition within 24 hours of
presentation among non-transferred cases was 71%; a small
minority (5%) of patients admitted and managed for ACS did
not get an ECG during their entire hospitalisation.
3
‘Right now, we are not able to do ECG for our patients
because our ECG machine broke down a few months ago.
We are in the process of getting one….at the moment what
we are doing, we are sending the patients to the cardiology
unit…to get their ECG done.’
Participants reported that cardiac biomarkers are generally but
not always available.
‘At times, also if the reagents for…the cardiac enzymes,
troponin, if they don’t have it in the lab that is a challenge.
We usually send, take the samples outside, we tell the
relatives to take it outside.’
Theme 2.2: Availability of reperfusion therapy
While Kenyatta National Hospital has a cardiac catheterisation
laboratory, primary percutaneous coronary intervention is not
available at all times. In-hospital cardiac catheterisation is also
not part of the routine management of ACS patients admitted
to the hospital, often because of late patient presentation for
ST-segment elevation myocardial infarction.
‘The hospital has (a) catheterisation lab but again we are
not doing primary PCI at the moment…so most of the
patients are being managed medically.’ ‘Why are they
being managed medically?’ ‘Cause (sic) many times they
will come late.’
All participants mentioned that thrombolysis for reperfusion
therapy for eligible ACS patients is currently not available at the
hospital and attributed cost as the primary reason the hospital
does not consistently stock thrombolysis medications. However,
the lack of in-hospital thrombolytic availability further limits
its use.
‘Currently this hospital does not stock [thrombolysis
medicines] in the hospital and therefore even if these
patients came on time and could benefit from lysis the
relatives have to be given the prescription to go out there
and purchase this medicine. So, you can imagine by the
time all that is done, the patient came late, by the time the
relatives go and buy these medicine, it is never going to be
on time.’
Respondents also acknowledged that many providers do not
have adequate training to administer thrombolytic therapy.
‘…if we were to get a patient who comes on time and
residents make that decision to thrombolyse this patient, are
they comfortable with the thrombolysis?’ ‘I would say no.’
Cost of cardiac catheterisation and intervention is another
significant barrier. Patients or their relatives need to purchase
coronary stents, which is not feasible during the acute treatment
period.
‘Of course, the patients have to pay for this angiogram
… it is always economically easier for the relatives if [the
patients] are discharged through the cardiology clinic, they
come and book for that angiogram, and they source for the
money…. So, we do tend to do angiogram usually in the
course of one week to a month.’
Theme 3: Guideline-directed in-hospital and discharge
medical therapy such as antiplatelets, beta-blockers,
statins and anticoagulants are largely available
Participants reported that other guideline-directed medicines
recommended by the current international ACS guidelines
such as the American College of Cardiology/American Heart
Association or the European Society of Cardiology are available
Table 3. Barriers to in-hospital acute ACS management at Kenyatta National Hospital
Hospital level
Provider level
Patient level
• No standardised triaging system for patients with chest pain or suspected ACS
• Inadequate number of ECG machines or lack of routine maintenance if malfunctioning
• Occasional inadequate availability of essential ACS diagnostic tests, such as cardiac biomarkers
• Lack of availability of some medicines such as nitroglycerine
• Thrombolytics are not consistently stocked or are not available most of the time
• There is a lack of standardised protocol or hospital guidelines for ACS management
• There is no dedicated coronary care unit and very limited availability of ICU beds and resuscitation rooms.
• Cardiac catheterisation laboratory is available but currently no primary PCI service
• No hospital-organised specific training for ACS or other cardiac emergencies
• Low level of training
on the management
of ACS
• Inadequate number
of staff with high
patient-to-nurse ratio,
especially in the medi-
cal wards
• Low level of knowledge
about symptoms of ACS
• Inability to afford medi-
cal treatment
• Self-medication using
over-the-counter medica-
tions
• Language barriers
PCI, percutaneous coronary intervention.