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at Kenyatta National Hospital, including aspirin, clopidogrel,
nitrates, beta-blockers, statins, ACE inhibitors, oxygen, morphine
and anticoagulants. Stock-outs are rare.
‘We have definitely the oxygen points and the oxygen
supplies. We have the analgesics, the operators are there.
Nitroglycerin would be there. Aspirin, clopidogrel would
be there. If maybe (there) was hypertensive emergency, the
drugs would be there. There would be the beta-blockers,
and ACE inhibitors are available.’
Similarly, guideline-directed medicines are available for
prescription at the time of discharge.
‘…of course they will be discharged with all the drugs
which are useful for coronary artery disease; then they will
be followed up in the cardiology clinic.’
However, participants acknowledged that even if these medicines
are available, many patients have limited or delayed access, largely
due to cost, which influences long-term adherence. Patients
may have to pay for these medications prior to administration,
especially in the casualty department.
‘The bad thing is that they have to dig deep into their
pockets to take care of [treatment]… the good thing also is
that the hospital allows us, especially in emergency set up,
allows us to waive all the cost.’
Theme 4: Lack of awareness and use of standardised
hospital protocol to guide ACS management
Most participants stated that they were not aware whether there is
a standardised hospital-wide ACS protocol to guide management
of patients. Two participants acknowledged that there is a
guideline for ACS management in the casualty department,
drafted by the emergency medical services of Kenya, although it
is currently not widely distributed to healthcare providers.
‘We don’t have any pinned-up protocols on the wall yet, but
there are some protocols we are using from the emergency
medical services of Kenya. We are able to disseminate
them to the doctors, right now we are in the process of
printing, we want to make them into small notebooks and
give the nurses and the doctors.’
However, awareness and use of any existing ACS protocol was
not universal.
‘We don’t have (a) protocol. When you get in, you do what
you see everyone else do.’
Theme 5: Most staff feel inexperienced managing
ACS patients
Most participants highlighted that they generally feel
inexperienced in managing patients with ACS. Participants
stated most of their knowledge on management of ACS cases
came from self-initiated review of international guidelines,
6
peers
or experiences from working in other institutions.
‘We follow guidelines, most of themare British or American
guidelines. European Society for Cardiology, American
Cardiac Society, but we only do what is available. And also,
sometimes the norms if you are a new resident, like when
I started working here, you find what other residents have
been doing. So that is what you do, or when you get an
ACS patient you consult, you have a resident who can tell
you this is usually done.’
Theme 6: Acceptability of interventions for
improvement of quality, including checklists, audits
and feedback reports
All participantsmade several suggestions onhowto improve existing
ACS care at Kenyatta National Hospital. Table 4 summarises
these recommendations, which are primarily targeted at hospital-
level infrastructure, provider-level ACS training, and community-
level awareness of ACS management. At the hospital level,
recommendations focused on increasing current diagnostic and
therapeutic capabilities, such as ECG machines and thrombolytics
and implementing a hospital-wide standardised ACS protocol. At
the provider level, the most common recommendation focused on
improving current training on ACS management.
We also assessed the acceptability of initiatives to improve
quality of care of ACS, such as checklists, audits and feedback
reports, which have been shown to improve processes of care in
ACS management.
7,8
‘A checklist would definitely be very useful because a lot of
the times as residents we manage all sorts of different case
presentations... So I think having a checklist just reminds
you that there might be an important step that I skipped so
you can easily go back to it before it’s too late.’
Most participants described the use of other checklists at the
hospital for intensive care unit (ICU), tuberculosis (TB) and
trauma services.
‘ICU and TB and chest wards have existing checklists that
are standard across public hospitals, especially the TB
checklist that has standardised the care for TB patients
in the hospital. If there is a specific checklist for ACS
patients, that could improve the care.’
Table 4. Participants’ suggestions for future improvement in quality of ACS care
Hospital level
Provider level
Patient level
• Increase diagnostic capabilities, primarily increased number of ECGs in the hospital
• Have a dedicated ECG machine at triaging point in the accident and emergency
room
• Ensure consistent availability of thrombolysis medicines
• Improve other laboratory capabilities, such as point-of-care cardiac markers
• Implement a standardised protocol or hospital guidelines for chest pain triaging and
ACS management
• Build a dedicated coronary care unit
• Improve knowledge of health-
care providers on ACS manage-
ment guidelines
• Training and protocol on safe
administration of thrombo-
lytics
• Hospital-sponsored advanced
cardiac life-support training
• Public health initiative to improve
patient knowledge on recognition of
ACS symptoms and need for emergent
medical evaluation
• Evaluate mechanisms to cover medical
costs for ACS care, including expan-
sion of the national health insurance
fund to cover essential treatments